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Interview with Governor Brown's Top Health Official on Doctor Shortages and the Federal Health Law
This is an edited version of an interview between Capital Public Radio's Health Care Reporter Pauline Bartolone and Secretary Dooley.
Dooley: There's a shortage of all medical professionals. There is a shortage of primary care physicians. That's well documented. But it is a shortage as measured by old standards. The measure of numbers of professionals to population, California has exceeded for a long time. We are very much more efficient than other places. So on some level, there's a definitional calculation of what is a shortage? We have fewer physicians per resident of California than most other states. Part of that is a shortage. Part of it is that we do have more demand than we have supply of physicians. But part of it results from our greater efficiency and longer use of more professionals as a team, and that is at the heart of the Affordable Care Act. That's partly why California is in the lead in implementing the Affordable Care Act. It also leads to why California embraced it so early, because we have been on the forefront of reforming our system and moving to coordinated care and integrated care long before the Affordable Care Act was passed.
Bartolone: So as you said, California's a leader in embracing this team-based care model. Are you saying that because of the use of that team-based care model, Californians are getting the primary care they need?
Dooley: I think Californians in need of primary care are particularly well served by this history. There are people who need care that aren't getting it. Not only the uninsured, but those who live in rural areas for example, and I worked at a children's hospital in Fresno, the central valley of California, and it was very difficult to recruit not only primary care physicians but specialists. So you have a distribution problem in California. If you live in higher populated areas, more coastal communities, you have more access to all the care, primary care as well as specialty care. For all of those areas of rural California that don't have enough primary care physicians, they have usually even a greater shortage of specialists. So it is an industry-wide problem that relates in large part to geography.
Bartolone: So can you tell me a little bit more about what the state is doing to try to get doctors where they're needed?
There are a number of things that we will do over time. Certainly there will need to be an increase in medical education. We have issues with the residency programs and having enough slots. We have just come through almost a decade of budget crisis and recession in California, that we are just coming out of. We've worked very hard to get to the balanced budget, the starting point. We still have a lot of work to go in this recovering economy, so we are going to have to invest very carefully and wisely. Training new professionals will take time. Any investment in medical education is not going to produce more doctors for five or six years, so we do have to address the way we deliver care and that is also at the heart of the Affordable Care Act. There are many incentives in this federal law to create a variety of kinds of "medical homes"…We can change the way we pay for care that incentivizes health instead of treating illness.
"One important part of this conversation is about the expectations of the patients themselves."
There are ways to expand the paraprofessionals, the others that are parts of those medical teams, and of course there is legislation pending now to consider expanding the scope of practice of other health professionals that allow them to do more things that are consistent with their training.
There is some evidence in California that we are investing more in the training of some medical professionals than our licenses allow them to do. There are other states that are ahead of us in that regard, and that will be an important and robust conversation. But there are many ways that we can address this issue.
One important part of this conversation is about the expectations of the patients themselves. We come to our health care with a very "Marcus Welby" attitude about what we expect from our physicians, and physicians haven't practiced in the 1950s and 1960s television "Dr. Kildare" / "Marcus Welby" mode for some time. But many of us expect that if we don't see the physician, we haven't received health care, and yet there are many, many ways in which health care is delivered by other professionals: by nurse practitioners, by physicians assistants, from home health aids, from optometrists, from podiatrists, from chiropractors, from acupuncturists. We have many professionals that deliver care in California effectively and that are making our system work and we're going to have to change some of our attitudes I think as patients about who we need to see and empower others in the system.
"Many of our health care needs relate to chronic conditions...And the treatment for those conditions requires a lot of management. A lot of that management doesn't have to be done by the physician."
Many of our health care needs relate to chronic conditions: asthma and diabetes are two examples. And the treatment for those conditions requires a lot of management. A lot of that management doesn't have to be done by the physician.
Bartolone: A source at the California Academy of Family Physicians… said that primary care doctors can't afford to see Medi-Cal patients because the reimbursement rate is so low. What is your response to the idea that part of the problem with the doctor shortage is the low reimbursement rate in Medi-Cal?
Dooley: Well, California has a low cost per beneficiary. We are the most efficient state in the country. We do pay rates that are lower than other areas, but we provide services in many more ways than others do… So we provide more care through the provision of service by other professionals in California than any other place as well. So there is a great deal of primary care that is provided to Medi-Cal beneficiaries by other than physicians. And much of that care is very high quality and acceptable.
We are also looking at the pressure that this expansion will put on the rates, and we are very diligent about doing access studies to determine where we are not meeting the needs of people who depend on Medi-Cal. We make adjustments to the rate, and the system does have a process for making adjustments.
Bartolone: [Is] the doctor shortage problem… really a shortage of doctors serving the poor in California, not a problem of geography?
Dooley: There are many economic issues in health care delivery, and the Affordable Care Act was built upon a capitalist economic model where you pay and you are rewarded and there are financial incentives. And our financial incentives in health care are not unlike they are in hotels or food or transportation or anything else. If you pay more, you get more, and health care hasn't been different in that regard. When you can pay more, you get more services.
But we also have a safety net system that is very robust, and particularly in California we have been a leader in eligibility, in level of benefits, and in services provided that far exceed the minimums in other states.
Pauline: I wanted to ask you a little bit more about what's going to happen next year, particularly with the doctor shortages that we have right now. It's estimated that more than a million Californians will be enrolled in new Medi-Cal coverage. So you expect there to be a scenario in which they may have Medi-Cal cards but may not have a doctor to see?
Dooley: I think that the implementation of Obamacare is going to take some time. There is going to be a transition to this new system. It's going to start in January, and it's going to take us several years. People with Medi-Cal cards now sometimes have delays in getting the care that they need. People with [private] insurance sometimes suffer delays in getting an appointment. We can't get everything we need right when we need it. We have a pretty good system of triage where in emergencies and critical conditions, the care is provided, and that will be our highest priority as we transition to Obamacare over the next few years. We set our priorities for those that have the most critical needs…
"This isn't a government-run program; it's a government-financed program. And the marketplace will still operate, and while there were many advocates of a single-payer or England-style system, that's not what we have."
But this isn't a government-run program; it's a government-financed program. And the marketplace will still operate, and while there were many advocates of a single-payer or England-style system, that's not what we have. This is a system that is built on the private sector capitalist economic chassis if you will, and it will work the way market systems work. In some ways they work very well, and in some ways they work less well.
Bartolone: You alluded to folks with private insurance who will get insurance cards next year as well. Do you imagine that they might have problems seeing doctors as well?
Dooley: We are going to be moving large numbers of people who have not had access to regular care into the system. That's going to take some time. People who don't have relationships with their physicians are going to have to locate and establish relationships with physicians, much as you do when you change jobs or change insurance companies… There is going to be a rather long transition to make this work, and there are going to be some dislocations and there are going to be some disappointments. But if you take a long view of this, it will be very, very beneficial to many people.
Bartolone: Is there anything else that you want the public to know about new coverage starting next year?
Dooley: The Governor has said that Obamacare is both historic and heroic, and it is indeed. But nothing is free, and there are going to be costs associated with this implementation: costs to the California budget, costs in time, costs in attention, costs to the delivery system and costs to the patients - of the patients, if you will.
There will be speed bumps that we will have to slow down to get over, but we will have, as we look back five years, ten years from now, and be very grateful that we have made this investment and that California again was a leader in taking advantage of the opportunities that the Affordable Care Act presents.
"There are going to be costs associated with this implementation: costs to the California budget, costs in time, costs in attention, costs to the delivery system and costs to the patients"
…There are significant changes to the ways the insurance companies do their business, limitations on their administrative overhead and profit, certainly the limitation that prevents them from only insuring healthy people. We will spread the cost of the people who have chronic conditions and have been excluded from the health insurance across. That's going to change the rates that the rest of us pay…Some of us will pay more at the beginning, but as we then encounter the system and need the care either through injury or illness, the system will be there for us.
Bartolone: I wanted to ask you about Senator Hernandez's bills to expand the scopes of practice of non-physicians. I know these bills are in their early stages, but in general, do you support the idea of expanding the scopes of practice of non-physicians to help meet the demand for primary care?
Dooley: We haven't taken a position on the Hernandez bills as this administration. I do believe that it is a very important conversation. We have to talk about the investment that we make in the education of medical professionals and how we can maximize the return on that education investment. We have to be very conscious of quality and oversight and the levels of training that people receive. Clearly physicians are the captains of the teams of care. They will continue to be. How we can use the training that we invest wisely and adjust the licenses if they need to be adjusted, and I don't know at this point whether they do or not, but I think that there is a very important conversation that we should bring everyone to the table to have.
Nurse practitioners, optometrists and physicians assistants and pharmacists are among those professionals that we invest a great deal of education and there may be things that they can do that we haven't modernized our licenses to allow. But the jury is out for me.
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