Sumana Reddy, a primary care physician, struggles with thin financial margins to run Acacia Family Medical Group, a small independent practice founded in Salinas 27 years ago.
Reddy cannot match the pay offered by the larger healthcare system. This is difficult, exacerbated by a widespread shortage of primary care physicians.
The shortage is primarily linked to a relative lack of fame associated with low wages and primary care, making recruiting difficult.
“It’s certainly difficult to expose medical students to this type of integrated healthcare pleasure early in their careers,” Lady said. “The relationships we build and the care we provide will help people live longer with a better quality of life.”
Wanting to increase revenues so that acacia can afford to pay more, Reddy has signed up for practice on alternative payment methods with health plans that offer bonuses to meet specific primary care goals related to breast cancer, blood pressure control, breast cancer, colorectal cancer and mental health.
Such performance arrangements are just one of many efforts by industry players and state officials to tackle the issues that plague primary care.
Medical students often choose to enter primary care, but that’s not good for patients. People with regular primary care providers are more likely to receive preventive care that feels empowered to avoid serious illnesses and advocate for themselves. They also rely on or refrain from caring for costly emergency room visits, who are unlikely to encounter language barriers.
Six years after the influential California Future Health and Labor Commission created a set of recommendations to plug in the forecast shortages of 4,100 primary care providers in 2030, many public and private initiatives have grown around the state to address the issue.
They include new residential slots, debt forgiveness, medical school tuition waiver, new ways to pay physicians, expand the role of nurse practitioners, and statewide goals to increase primary care spending. Some of these efforts have been allocated hundreds of millions of taxpayer dollars.
However, many academic and medical professionals believe these moves, while intended, are scattered and inadequate.
“The work is there,” said Monica Soni, chief medical officer for California, California, the state’s Affordable Care Act health insurance market. “We’re worried it might be a little too late. I think we’ll be a little too quiet.”
A study published by the California Healthcare Foundation in 2022 found significant advances in some of these goals, including recruiting students from low-income households and communities of color. Another analysis from the foundation showed that between 2020 and 2023, California jumped over roughly 10 spots in the state rankings of per capita primary care residents and fellows.
However, most recent state data shows that nearly 15 million Californians live in areas where there are not enough primary care providers to meet the needs of their patients.
State budget constraints and potential federal spending cuts, particularly Medicaid, could exacerbate shortages in areas already desperate for clinicians, and attenuate hopes of creating a robust primary care system that virtually everyone agrees with state officials. Federal cuts could also collide with medical training and hospital systems.
“Many of us are very scared of the threats from both the Trump administration in Congress and the Republicans,” said Kevin Grunbach, professor of family community medicine at UC San Francisco.
Acute primary care shortage
The shortage of primary care providers in California, including doctors, nurses and physician assistants, is most severe in the state’s rural areas, particularly in the northern and central valleys. State data shows that the entire country county, including Del Norte, Madera, Tulea and Yuba, are designated as shortage areas. Several dense urban areas are also faced, including parts of Los Angeles
Shortage.
Many Californians need to face months of waiting to make an appointment, travel long distances, or go to the emergency room for emergency medical needs.
In Chico, 90 miles north of Sacramento, the town’s only hospital emergency room has seen a sharp rise in cases over the past decade due to a lack of primary care providers in the area.
“There are a lot of things that people who don’t have a primary care provider, because it’s not enough, but they’re going to be ER when they need daily care,” said local internist David Alonso. “Then the ER says, ‘OK, you need to follow up with your primary care provider’, and they say, ‘We don’t have it.’ ”
Yalda Jabberpur, director of the Robert Graham Center for Policy Research, a health policy think tank, said that failure to invest steadyly in primary care has robbed the public of its profits.
The sector has historically been underfunded, accounting for less than 5% of national health spending in 2022, according to the Milbank Memorial Fund, a national nonprofit focused on population health and health equity.
The results are clear. The US spends more per capita health care than other developed countries, but Americans are not healthy. Chronic conditions such as heart disease, diabetes, arthritis, and Alzheimer’s disease, and mental illness account for 90% of the $4.5 trillion spent on health care each year.
Medical students, often facing incredible educational debt, are increasingly choosing a more paid specialist field than primary care. According to one study, the average salary for family medicine physicians is just over $300,000, and over $763,000 for neurosurgeons.
“If you pay more than $300,000 to go to medical school, you want to be a neurosurgeon. You don’t want to be a family practice doctor,” said William Barcelona, vice president of government affairs for the Los Angeles-based Association of Professionals, representing 360 medical groups and the Independent Practice Association.
Barcellona said high housing costs in Golden State are also making adoption difficult.
But it doesn’t just soften your enthusiasm for primary care. Also burnout from so many unpaid hours spent recording details of medical visits in electronic health records. Scattered with insurance companies for treatment permits. Responding to patients’ calls and emails. Or, for professionals with the right expertise, often search widely in the Healthcare Desert.
Debbie Lee, daughter of a Mong immigrant in Laos, experienced this type of frustration firsthand.
The cultural and linguistic barriers her family faced motivated her to pursue internal medicine. Lee worked part of the residency at a community clinic serving the Hmong people in the Sacramento area. She loved not only her colleagues but her patients as well. But she was burdened with outdated techniques that limited the number of patients she could see. “I just saw myself burning out like I was in that environment,” Lee said.
When the clinic invited her to stay, she declined and worked in a larger health system.
Solution to the shortage
In addition to residential, other efforts support primary care.
San Mateo Health Plan provides grants to help medical practices maintain and add primary care staff. In exchange, MEDI-CAL, a single physician serving patients in California’s Medicaid program, must show that they have increased patient load and have hired new employees.
Provider for 5 years.
The idea is to provide capital so that doctors can hire the staff they need to run their practices efficiently, increase their pay, provide bonuses, and hire the staff they need to take sabbaticals. Such efforts coincides with one of the main drivers of the 2019 Workforce Report. It’s about increasing investment in primary care.
California recently joined several other states, including Connecticut, Oklahoma and Rhode Island, setting goals to increase primary care spending. So far, these policies have had mixed results.
Late last year, California’s Healthcare Affordable Prices Bureau set a target for 15% of total medical expenses to become primary care accounts by 2034, more than double the current share. It relies on the goodwill of a health plan to work with a health care provider, and it does not impose any requirements.
Richard Chronick, a UC San Diego professor of public health and a member of the OHCA board of directors, says that increased spending on primary care means better pay and more people working in this field to more people. “It’s a huge change. Will it happen? I don’t think anyone can predict the future for sure.”
“There could be some of that increase, but at some point it might need to be mandatory,” said Stephen Schotel, professor emeritus of health policy and management in Berkeley, California.
In the report, the Workforce Committee also cited the importance of alternative forms of primary care, which provide additional cash for quality care. Affordable offices have set goals to encourage such payment methods. The aim is to convert the system from something that all health services have price tags to something that handles people in a comprehensive way, and what adheres to healthcare standards will bring more money to doctors and their office staff.
Such arrangements are common among HMOs, but are not often found in primary care practices. If they exist, different health plans and other payers are generally designed differently. In other words, primary care practices manage multiple payment models and add administrative burden.
Reddy’s Family Practices participate in a one-year demonstration project launched in January.
The project brings together 10 independent practices across the state with three large insurers, HealthNet, Etna and Blue Shield, with the aim of improving care while increasing the revenues of health groups. It is managed by two industry groups, the Integrated Healthcare ASSN. And California’s joint quality cooperation.
In addition to conventional payments for either rendered services or monthly per-member allocations, medical practices receive bonuses to achieve goals and improve performance on core measurements.
Participating practices also receive monthly per-patient payments for “population health management.” This means managing the collective health of the patient. You can also search a single platform to find all patients covered by any of the three plans.
In addition to less effort to pay and manage, the health plan pays for the “practice coach.” Their job is to help primary care groups achieve their goals and provide more seamless care.
“We’re one of the people driving the project,” said Todd May, medical director of Healthnet’s Commercial Health Plans. “In addition to better results, we want to see a stronger, more robust and more satisfying primary care workforce,” he said.
Reddy hopes that Acacia’s revenue can be increased by 20% thanks to the extra money from this and other performance arrangements. She said it would allow her to raise staff payments and hire a new clinician.
Over the years, her practice has limited the number of patients she has accepted. But after searching for most of the five years, Reddy hires a new doctor at halftime, with another doctor coming in June this year.
“This is the most hopeful thing I’ve felt in decades,” Lady said.
Wolfson and Sánchez write for KFF Health News. It is one of KFF’s core operating programs that produces detailed journalism on health issues. It is an independent source of health policy research, voting and journalism. Philip Reese contributed to this report.
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