A new report on California's physician workforce has set off a war of words over how many doctors are leaving the state due to dissatisfaction with managed care and widespread financial woes.
"Both generalist and specialist supplies have continued to increase over the past six years at faster rates than that of the general population," the report concludes, and "there is no evidence" of large numbers of physicians leaving California. The report finds that the overall state ratio of physicians per 100,000 population has grown from 177 in 1994 to 190 in 2000, a number that exceeds the recommendation of the Council on Graduate Medical Education (COGME).
The study, "The Practice of Medicine in California: A Profile of the Physician Workforce," was published in April by the California Workforce Initiative, a division of the University of California-San Francisco Center for Health Professions. It was funded with grants from the California HealthCare Foundation, a not-for-profit organization that is devoted to improving quality and access, and the California Endowment, a private foundation.
Researchers used physician practice data gathered primarily from the AMA Masterfile and a 1998 survey of nearly 2,000 physicians.
The California Medical Association's CEO, Jack Lewin, M.D., says the study's numbers are inaccurate and its conclusions could lead stakeholders to bury their heads in the sand while a healthcare crisis looms.
"We can't allow the UCSF study to encourage complacency," Lewin says. "Most other indicators are saying the pressures of the increasing numbers of uninsured and underfunding in the commercial marketplace and in the publicly funded programs, combined with the increased cost of living, have made California an unfriendly place for doctors to practice." The CMA is conducting its own survey, intended for publication later this year.
The report's authors do not deny that a statewide emergency is pending, only that it can be prevented with more doctors. They claim the more important issues are how to better distribute doctors and achieve balance between primary care physicians and specialists.
"There is a crisis, I just don't think it's that there aren't enough warm bodies filling physicians' white coats," says co-author Kevin Grumbach, M.D., director of the UCSF Center for California Health Workforce Studies and a practicing physician. "It's that (doctors) are tremendously maldistributed across the state."
Data on California's physician supply shows great variation statewide, according to the report. The ratio of doctors to the general population ranges from a high of 238 physicians per 100,000 residents in the San Francisco Bay Area to a low of 120 physicians per 100,000 people in the South Valley/Sierra region.
Physician supply at the county level varies even more widely. Even in those counties abounding with physicians, shortages exist in communities with high minority populations, the report acknowledges.
Grumbach says the findings are consistent with what's happening nationally, with physician supply remaining in a position of growth as a result of policies that expanded slots for residencies in the 1980s and 1990s. Lewin says the early, high penetration of managed care coupled with a rising cost of living and employers who out-negotiated the rest of the country for lower premiums have created a problem that is unique to California.
Local news media from urban markets continue to report on county and regional medical societies that say they are losing physicians. The CMA worries that the study's information is misleading, in part because it fails to distinguish just how many hours per week "active" physicians are working.
The study found almost 90,000 active allopathic and osteopathic physicians in California in 2000. After eliminating residents, retirees, federal physicians and physicians working less than 20 hours per week, the report based most of its analysis on 65,000 patient-care doctors.
"Nowhere in the report does it say how many physicians are working reduced hours," says CMA spokesperson Peter Warren. He says data collected by the Medical Board of California shows at least 7,000 fewer physicians, or 82,900, were licensed and residing in California in 1999-2000. The Medical Board counts all doctors holding a current California medical license and does not track practice details, however.
Grumbach seems puzzled by the CMA's reaction. "I am more than willing to publicly admit the data we use are far from perfect, but it's the best we have," he says. "It's what most researchers use. If something's going on, it's just not appearing on that radar screen yet.
"Maybe the common ground created by this report is generating a controversy that points out the crying demand for the improvement on data of physician supply in the state," Grumbach says.