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Trying To Provide Solutions to Patient Access

California is in a bit of a fix, according to Senate member Ed Hernandez (D-West Covina), chair of the Senate Committee on Health.

The state doesn’t have enough physicians and other primary care providers now, according to some estimates. That shortage will become more acute in 2014 when the Affordable Care Act brings up to four million newly insured Californians into the system, looking for providers to care for them.

“2014 is essentially here,” Hernandez said yesterday at a Senate health committee hearing on primary care workforce issues. “We have had a historic piece of legislation pass at the federal level, the most historic health legislation since the Lyndon Johnson administration, when the Medicare Act was passed. But there are a lot of unknowns still, including how to implement it.”

It’s one thing to make affordable health insurance available to more Californians, he said, but it’s another thing to ensure they can actually get care in a timely manner.

“As we wake up on 2014, everyone may have a health insurance card, but it may be that not everyone will have access to a health provider,” Hernandez said.

The current primary care workforce shortage hits two areas in particular, according to researcher Catherine Dower of UCSF: the rural areas, and in urban areas among communities of color.

“The biggest problem is the maldistribution of providers,” Dower said. “Physicians tend to congregate in urban and suburban areas and along the coast. For every one new physician who goes to an underserved area, we have four that go to already-served areas.”

When you combine that with the statistic that 30% of California’s physicians are 60 years old or older, and that there are more physicians retiring every year than are entering the workforce, the access picture gets a little scary, Dower said.

She said training more primary care physicians is not the only solution. Increasing the number of new physicians trained in California would be costly and certainly a long-term project, she said. But she had a few ideas for things that might work now:

• Loan repayment programs for medical students and other new providers can direct providers into underserved areas.

• Enhanced telehealth services is a reasonable way to diagnose and treat patients in underserved areas.

• Expand the legal scope of what physician assistants and nurse practitioners are allowed to do. “The PA’s and NP’s scope of practice should match their skill level,” Dower said.

• Improve the education pipeline and train more providers who have a connection to underserved areas.

The quickest legislative fix, she said, would change the scope of practice for mid-level practitioners, allowing them more authority to treat their patients.

“I’ve looked at the NP data extensively,” Dower said. “They can do about 85% of what a physician can do. The quality and outcomes compared to physicians are the same or better, and patient satisfaction is the same or better. Whenever I hear the differences [between people over] expansion of scope of practice, all of those [discussions] appear to be political compromises.”

Steve Barrow, from the California Workforce Development Council, said that the group recently released a plan to deal with the health workforce, and is looking for comment on the ideas. “We just posted an action plan based on 113 recommendations,” Barrow said, “and we’re looking for input till Mar. 30, that’s the last day for feedback.”

Ronald Cook flew out from Texas to present an entirely different idea. He represents Texas Tech University, which recently started a three-year program at its medical school, rather than the usual four-year post-graduate education.

“The idea is to produce physicians a lot more quickly, and save a year of medical education debt,” Cook said. “We’re trying to get students out into the community faster, a year sooner than normally, at about half the cost.”

At this point, Hernandez said, he’s willing to consider a lot of possibilities.

“We will need an increased workforce, there is no doubt,” Hernandez said. “We need to make sure there’s enough workforce out there to get everyone access to care.”

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