California Health Report | HealthyCal - Part 3
 

California Health Report

  

‘Show Me The Money’

Published: April 28, 2013 | No Comments

Caring for Our Most Vulnerable Without a Budget

By Matt Perry
California Health Report

Imagine taking a job without knowing how much you’ll be paid. Or having your car fixed without knowing the cost.

That’s how state health insurers and our most vulnerable patients – the old, sick, and poor – feel about California’s latest plan to squeeze them into a new managed care program that may be woefully unprepared for a transition scheduled for the fall.

Officially announced in March and dubbed the Cal MediConnect program, the initiative targets patients who are eligible for both Medicare because they are either elderly or disabled and Medi-Cal because they are also low-income. The government calls these people “dual eligibles” because they qualify for both health programs.

The highly optimistic kickoff is slated for October 1st.

The goal? Give these patients better service, coordinated by the health plans to streamline fragmented medical care and social supports that historically have been managed separately by the two programs.

The problem? Money.

A month after the announcment, public and private health insurers in eight California counties that will pilot the project are awaiting answers to this simple question: “How much are we getting paid?”

“That’s the million dollar question,” says Wendy Peterson, director of the Senior Services Coalition of Alameda County. “And we’re baffled by it. It seems a little bit backwards.”

Perhaps even more backwards than similar transitions.

In 2012, California went through a chaotic transition when it tried to slim down the state’s adult day health care program by converting it to managed care and shedding some clients. Overseen by the state’s Department of Health Care Serives (DHCS), that transition affected just 35,000 people – about 80% of whom survived the patient purge.

This year, the department is back with another conversion to managed care, yet the stakes are much higher.

There are a whopping 1.1 million “dual eligible” Californians, although the three-year project affects only about half that number in its eight pilot counties. A little more than 400,000 are expected to participate in the voluntary program.

The state eventually hopes to save a billion dollars annually when all dual eligibles participate.

Yet health insurers were burned badly over the last two years when forced to manage the state’s program known as Seniors and People with Disabilities.

“The plans lost their shirts,” says Peter Szutu, president and CEO of the Center for Elders’ Independence.

So why would the health plans take on yet another vulnerable population and lose even more money?

“We said essentially the same thing to the state,” says Howard Kahn, CEO for L.A. Care Health Plan. “You have to fix the SPD rate situation before we can start this dual demonstrations project.”

“The rates are key to the success of the demonstration,” agrees Abbie Totten, director of state progreams for the California Association of Health Planas.

Yet other questions remain. Lots of them.

When will the three-way contracts among the health plans, the state, and the federal government be inked? How can understaffed, financially battered counties prepare for the complex transition? What creative solutions can the plans invent without knowing their budget?

All that’s known today is that reimbursements decrease as the three-year pilot project continues – economic arm-twisting designed to force coordinated care and lower costs. Many patients fear that managed care is really code for cutting services to those who need them.

“It’s not about saying no to the right services,” counters Abbie Totten of the health plan trade group. “It’s about utilizing the right services at the right time and not overutilizing services.”

Still, many aging experts warn that coordinated care may actually be more expensive.

“Theoretically, this model will save money,” says Szutu. “But the rates that are being offered may not give the plans enough of a cushion so they can complete that learning cycle and get efficient and improve quality. They may still ration and cap benefits as they have throughout the years.”

Critical to the discussion are the two types of health plans in the counties: smaller, community-based plans that work almost solely with impoverished patients; and the much larger commercial plans that are typically for-profit enterprises and have less experience serving the poor.

“We have a greater amount of our existence at risk,” admits Kahn of his community-based operation. “Health Net’s a national corporation and we’re a local plan.”

Indeed, a look under the hood of the duals project reveals very different motivations. For humanists and optimists… coordinated care for the vulnerable. For the cynical… a loss leader that will help keep existing state contracts and lead to eventual growth in others.

“It’s really about capturing this revenue and this line of business,” said one observer close to the situtation. “The big private plans are confident they can make money.”

Revenue? Line of business? Indeed, last year, the global banking giant Barclays summarized the duals demonstration project this way: “We estimate the size of the overall opportunity in California to be approaching $17 billion in revenues in 2013, and more than $32 billion in revenue in 2015.”

Should California’s most vulnerable citizens – the old, disabled and poor – fear they’re being reduced to a medical spreadsheet?

“The state does have a bottom line they want to look at,” says Peterson.

“It’s a poker game between the providers and the state,” says Gary Passmore, vice president, Congress of California Seniors.

Despite the looming start date, some plans say they are standing firmly for quality over profits – and won’t be rushed into a haphazard launch.

“We’ve decided we have to do well by our members at the beginning of the program,” says Kahn. “If the rates come in and we can’t do a good job for our members, we won’t do the program.”

 

California has most at stake in immigration debate

Published: April 28, 2013 | 1 Comment

By Daniel Weintraub

As Congress begins what is likely to be a lengthy and contentious debate over immigration reform, California has a huge stake in the outcome.

We have the nation’s biggest population of immigrants, both legal and undocumented.

We are the country’s biggest farm state, measured by the value of our production, and those farms are largely dependent on immigrant workers.

And we are, arguably, the innovation capital of the world, with much of that innovation driven by immigrant engineers, software writers and entrepreneurs.

If Congress and President Obama can somehow agree on legislation that normalizes the status of immigrants already here, secures the borders, and fixes problems in the legal immigration system, California will almost certainly be the biggest beneficiary. This is something that could help rich and poor alike, and most people in between.

The proposal released earlier this month by a bipartisan group of eight senators seeks to do just that.

The legislation would create a path to citizenship (some call it amnesty) for those here without documentation. It would create a new guest worker program for agriculture and other low-wage industries. It would expand the number of visas available to highly educated people and entrepreneurs. And it would put in place new measures aimed at reducing the flow of illegal immigration.

Why are all of these things so important?

California is home to about 10 million foreign-born residents — more than twice as many as the next biggest state, New York. Those immigrants represent more than 25 percent of the state’s population and more than one out of every four immigrants living in the United States.

California also leads the nation in undocumented immigration. Estimates peg the number of undocumented immigrants here at about 2.5 million.

Most of those undocumented immigrants live on the edges of society. They are not eligible for welfare or other public assistance or routine health care, although they are treated if they show up in a hospital emergency room. They work in a cash economy, often for below minimum wage and in unsafe conditions, because they are in no position to complain.

While as a group they are probably a boost to the economy because their low wages increase overall productivity, they do depress wages and take jobs from others on the lowest rungs of the economic ladder, including many other immigrants. Since they are not going to be rounded up and sent home, it would be better if we found a way to bring them out into the open so they could live normal lives and work under the same rules as everyone else.

The Senate compromise tries to do this in a couple of ways. First, it lets undocumented workers who were here before the end of 2011 to register and seek legal resident status, which could take a decade or more. They would have to pay fines and any back taxes owed, learn English and meet work requirements. As a group, their ability to obtain legal status in ten years would depend on the nation meeting benchmarks for border security.

The bill would also create a new guest worker program for up to 200,000 low-wage workers per year and separately expand a guest worker program for agriculture, with up to about 330,000 farmworkers allowed into the country to work. This is an important step because most it would allow workers to enter and leave the country legally, and it would regulate and, probably, raise their wages. The current system actually creates incentives for illegal workers, once here, to remain, even if they lose their jobs, because they fear that if they leave they will never be able to return.

Just as crucial, and only slightly less controversial, are provisions to allow and even encourage more high-skilled people to come to the U.S. and remain here. The bill would raise the cap on a visa commonly used for high-skilled workers from 65,000 to 110,000 per year, with 25,000 more reserved for immigrants with advanced degrees from a U.S. school.

A new, so called “merit visa” would allow 250,000 immigrants per year under a points system, with points awarded based on education and employment, among other factors. And a special “start-up” visa would be available for up to 10,000 foreign-born entrepreneurs who create companies here that would create at least five jobs and have at least $500,000 in funding from investors.

Although some groups representing engineers have protested the expansion of visas for high-skilled workers, studies suggest that more immigration from this group will, over time, mean more jobs, not fewer. A recent study showed that immigrants created about half of the start-up companies in the Silicon Valley.

Finally, the bill includes provisions to improve border security. It sets a goal of providing surveillance of 100 percent of the border with Mexico and turning back 90 percent of those seeking to cross illegally. It envisions using drone aircraft, additional agents and, if necessary, more fencing. A new online system for checking the immigration status of potential workers would also be established.

The details of the proposal will be examined in Senate hearings and debate over the coming weeks, and later in the House of Representatives. There will probably be some changes.

But if the basic outlines of this compromise survive, California could see a path to citizenship, and out of poverty, for millions of its residents, the creation of thousands of new jobs, and a more secure border. In short, for California, this could be the most important piece of federal legislation in a generation.

California has always been a state of immigrants — from Mexico and Spain, from the United States before statehood, from Asia, Europe and Africa. Our success has been built on immigration (and domestic migration) as industrious, ambitious and creative people converged here from all over the world.

Now, with our growth slowing and our population aging, immigration will be more important than ever. Getting it right is crucial.

Daniel Weintraub has covered California public policy for 25 years. He is editor of the California Health Report at www.healthycal.org

 

Benefits in federal health reform may not entice small businesses

Published: April 25, 2013 | No Comments

Small business owner Virginia Donohue provides her employees at Pet Camp in San Francisco with health insurance benefits - but the ACA tax credit only covers a fraction of the cost.

By Callie Shanafelt
California Health Report

The federal Affordable Care Act kept the nation’s employer-based health insurance system intact – and that decision may leave small business struggling to provide health care to their employees.

The Affordable Care Act tries to fill cracks in the employer-based system, so that more people will have insurance and care will become more affordable for everyone.

But critics say provisions in the Affordable Care Act aren’t enough to ensure that small businesses can provide coverage to their employees. Some provisions may actually discourage employers from providing insurance.

One provision already in place is the small business health-care tax credit, which targets businesses with small staffs and low salaries. Businesses that have fewer than 10 employees who are not paid more than $25,000 get a tax credit.

Currently, the credit is up to 35 percent of their costs, if they pay for at least half of their employees’ premiums. Next year, the credit jumps to 50 percent.

“That’s going to give some businesses enough confidence to take the plunge and offer health care,” said David Chase, California Director of the Small Business Majority advocacy organization.

Virginia Donohue, owner of Pet Camp in San Francisco, received the credit for the past three years. She employs twenty people who provide day and night care to 260 dogs and cats.

“Pet Camp’s philosophy is that everybody needs health care.” Donohue said. “Unfortunately, you get it through employment.”

Donohue began offering her employees a choice of health plans in 2000. She paid $30,000 for complete coverage for ten employees. Her costs skyrocketed over the next decade. Two years ago, she had to stop offering a choice of health plans to her twenty employees because it would cost her $121,000 a year, even with her employees covering more of the costs. She switched to only offering Kaiser, but she still pays $90,000 a year to cover 80 percent of the premiums.

These rising costs have driven many businesses to stop offering health insurance. As Donohue watched her costs rise over the past 10 years, other businesses stopped covering employees altogether. Businesses in California covering their employees’ health care dropped from 62 percent to 53 percent, according to a Robert Wood Johnson Foundation study released this week.

The tax credit was meant to make it worth it for businesses to cover their employees. The credit was helpful, Donohue said, but it was only $7,000 for her.

“Seven thousand a year is very nice,” Donohue said. “But when you’re paying $90,000 a year, it doesn’t change the picture.”

Donohue hired an accountant to do her business taxes, but the paperwork for the Obamacare tax credit is so complicated that she does it herself.

“I’m getting better at it,” Donohue said. The first year it took her six hours. This year she’s got it down to four. “At the rate an accountant charges, that can eat up a substantial amount of the credit,” Donohue said.

Richard Chassey, a small business accountant in Santa Rosa, gets the tax credit for all his clients who qualify.

“Although each situation is different, in my opinion the time to organize and prepare the paperwork is worth the tax credit,” Chassey wrote in an email response during the busy tax season.

Elizabeth Echols, Regional Director of the Small Business Administration, estimates that four million small business owners are eligible for the tax credit, totaling $40 billion dollars nationally. But the program has been underused, with only five percent of those eligible taking the credit in the first year.

This is unlike other provisions of the Affordable Care Act, which have exceeded expectations. The Pre-Existing Insurance Plan was so popular the government had to freeze enrollment. More than three million young people have also added themselves to their parent’s health-care plan—many more than anticipated. More people are signing up for the Low Income Health Plan—the precursor to the Medi-Cal expansion—each day.

David Chase said business owners don’t know which benefits are available to them.

“If you don’t know about it, you can’t claim it,” Chase said.

Small Business Majority and the Small Business Administration are ramping up efforts to educate owners. In workshops of 50 business owners, Chase regularly asks who knows about the small business health-care tax credit.

“Maybe one person raises their hand,” Chase said.

The most common misconception among small business owners is that they will be mandated to provide health-care to employees, Chase said. In fact, businesses with fewer than 50 employees are not subject to the employer mandate.

Ninety-six percent of businesses in the U.S. have fewer than 50 employees. The vast majority of businesses with more than 50 employees already offer coverage, Chase said. “We are really looking at a very small sliver.”

But the majority of people work for companies with more than 50 employees, said UC Berkeley Assistant Law Professor David Gamage. Gamage, a tax attorney, spent two years in the Treasury Department figuring out how to implement the tax provisions of the Affordable Care Act.

Some of the tax provisions will have unintended negative consequences and possibly discourage employers from providing health-care to employees, Gamage said. This is because there are two competing health-care subsidies.

Businesses already get tax benefits for providing health insurance to employees, he explained. The government essentially subsidizes employer coverage now because the share of the premiums that employers pay for employees’ health plans is not considered taxable income.

For example, if an employee receives a $40,000 a year salary, the worker must pay tax on that amount. But if the employer pays an additional $5,000 a year for health coverage for that employee, the expense isn’t taxed.

This benefits higher wage earners more than low and middle-income employees.

“That’s essentially a historical accident that we’ve never been able to fix,” Gamage said.

The Affordable Care Act creates a generous tax subsidy for low and middle-income individuals who can’t get insurance through an employer. People get this subsidy by purchasing a health-care plan through an online marketplace; in California it is called Covered California. Anyone who makes less than 400 percent of the federal poverty level—$45,960 for an individual—will qualify for a subsidy toward their monthly premium.

These two separate subsidy systems may create a situation in which it is more beneficial for an employee to purchase coverage through the exchange – thus discouraging employers from providing health insurance.

“I predict that we’ll get a lot of gaming reactions,” Gamage said.

Instead, Gamage recommends combining and regulating health-care subsidies through one system.

Providing health-care to employees has been the top concern of small businesses every year since 1986 in a National Federation of Independent Businesses study.

“Both because it’s the right thing to do and it makes them more competitive,” Echols said.

Because of the complexity of the business provisions, David Chase recommends business owners speak with their accountant and insurance agent to figure out what is best for them. For the right business, he said, the tax credit could make it worth offering health care to employees.

“Don’t just look at the headlines,” Chase said. “Every business is very different.”

 

Q&A: Why sub-specialty pediatricians are in short supply

Published: April 24, 2013 | No Comments

Researcher Daphna Gans.

By Rosa Ramirez
California Health Report

California’s kids experience more problems obtaining subspecialized pediatric care than children in any other state, a new UCLA Center for Health Policy Research study has found.

The California Health Report spoke with Daphna Gans, a research scientist at the UCLA Center for Health Policy Research and assistant adjunct professor at the university’s Fielding School of Public Health, about why California has so few pediatric subspecialists.

Gans, a lead author of the report, will participate in a webinar April 25 to discuss the findings. The excerpts below have been edited for space and clarity.

Why is the issue more acute in California?

One of the possible explanations is that California has a very high cost of living. When you have physicians whose training is already extended, have a lot of debt to pay coming out of their program and are looking for a place to start their practice, it can be harder for them to be living in California than other states. They’ll take that into account when they accept a position.

Also, Medi-Cal – California’s Medicaid program—payments are also lower in California than in other states. So you have a combination of those two things that can lead to some sub-specialists to decide to practice elsewhere.

What access issues will we see in the coming years when Latinos become the largest racial group in the most populous state? What will that mean for these children?

We have found in the literature that access barriers are found across racial and lower socioeconomic status. Some of the disparities are not so much by race, but by language. If we see a large population of children of color having difficulty access sub-specialty pediatric care, it’s important to target that population because they are already at a disadvantage. The majority of the children with special health care needs are already children of color.

Some residency programs are considering reducing the availability of sub-specialty rotations to save money. What will the impact be and what are some alternatives?

I think that some programs are trying to reduce the cost. There’s also a debate within the schools on whether these pediatricians should have such an intensive training—if they can reduce some of the training and still have the practice and knowledge that would allow them to practice. The consensus is that intensive training is needed.

However, there are issues related to budgets. We recommend that Congress reinstate the $22 million in funding that was cut from the 2013 budget from the Children’s Hospital Graduate Medical Education funds. The funds support 43 percent of the nation’s pediatric sub-specialty training. Those cuts could result in 465 fewer pediatric subspecialty residency positions annually, which is a huge reduction.

 

A Cure for CURES

Published: April 24, 2013 | No Comments

Photo: @Doug88888/Flickr

Proposed legislation to fund, upgrade state’s prescription drug monitoring program

By Robert Fulton
California Health Report

In October of 2003, Jimena Barreto lost control of her Mercedes, running into and killing Bob Pack’s 10-year-old son Troy and 7-year-old daughter Alana. Barreto was under the influence of alcohol and prescription painkillers. She had been doctor-shopping, going from one physician to another to get multiple prescriptions for the drugs she craved.

Pack questioned how authorities could not have noticed someone obtaining an exorbitant amount of pain pills, and wondered why there was no system in place to monitor such action. He later learned that the state of California does have a Prescription Drug Monitoring Program, the Controlled Substance Utilization Review and Evaluation System (CURES). Pack also learned that CURES is both technologically inadequate and critically underfunded.

However, those shortcomings may soon be a thing of the past. State Senator Mark DeSaulnier (D-Concord) has introduced Senate Bill 809, which proposes funding measures to upgrade, operate and enforce the CURES program.

“It’s really frustrating for me because I’ve been at it for so long,” said Pack, who operates a mobile shopping application start-up in Danville. “I’m hoping this Senate bill finds its wheels and makes it through.”

The way CURES is supposed to operate is straightforward. Pharmacists are required to enter into the CURES database Schedule II through IV drugs that they’ve dispensed. Pharmacists, physicians who prescribe these drugs and law enforcement have access to the database. The purpose is two-fold: keep an eye out for patients that are doctor shopping, as well as doctors that are over prescribing dangerous, addictive pills.

Because of inadequate funding and outdated technology, the CURES program faces a number of shortcomings. Fewer than 13,000 out of a potential 200,000 subscribers are currently enrolled in the program. But even if everyone eligible were to sign up, the system as currently constructed would be unable to support them all, according to people familiar with CURES. And because of recent budget cuts, the program faces suspension as of July 1.

“It’s bare bones,” said Travis LeBlanc, special assistant attorney journal for the California Department of Justice. He said budget cuts have created delays in registering new users, updating the system, and supporting complicated queries to track doctor shoppers. “Bare bones means we have minimal employees working on it. They barely just keep the database up, that’s all they do. We’re dealing with a system that was created largely in the 20th century and we’re trying to use that now in the 21st century. There’s a lot of good reasons to invest in this, but bare bones is not good.”

Dr. Christy Waters, a psychiatrist with Kaiser Permanente, has been a member of the California Society of Addiction Medicine for 10 years. For the past six years, she’s acted as the chairperson of the CSAM’s Public Policy Committee. She characterized her recent interaction with CURES as being in “no man’s land.” She described the burdensome process of filling out an application, having it notarized, getting locked out of her account, and finding that no one is available to answer questions because of budget cuts.

“It really is a painful nightmare,” Waters said, noting that most physicians already have their plates full. “It just kind of limps along. It’s such an inadequate vehicle to do work that is so critically important.”

“The system itself from just a mechanical point of view doesn’t work very well,” Waters added. “But if you can log on, and you can get a hold of the information by logging on, then yes, it’s very helpful and it’s very effective.”

Senate Bill 809, co-written by DeSaulnier and Senate President Pro Tem Darrell Steinberg and sponsored by Attorney General Kamala D. Harris, promises to upgrade, fund and enforce the CURES program. A one-time tax assessment on health insurance plans and workers compensation insurers will fund software and hardware upgrades for the system. CURES would be maintained through an increase in licensing fees on medical professionals who prescribe or dispense Schedule II through IV drugs. The fee works out to about $2 for pharmacists and up to $10 for podiatrists, who pay the highest license fees. The bill also includes a tax on pharmaceutical manufacturers of Scheduled II through IV drugs to establish and support enforcement capabilities. The total cost of the bill in its first year is under $10 million.

Senate Bill 809 also includes a requirement for practitioners and pharmacists to register for CURES and consult the program, but the mandate would not take effect until the state completes the system’s upgrade in approximately two years.

“I think it’ll make a serious dent in prescription drug abuse, particularly the growth of it,” DeSaulnier said.

Pack’s story moved DeSaulnier, and this is his third attempt at getting legislation through to support CURES. The senator credits media attention to the effects of prescription drug abuse as one of the reasons why his current effort has a chance of being successful. He also cites the under $10 million price tag.

Aside from Pack’s story and others, DeSaulnier didn’t have to look far to find a personal connection to the plague of prescription drug abuse.

“My dad had substance abuse problems,” DeSaulnier said. “He was an alcoholic. He used prescription drugs, both antidepressants and pain killers, and he ended up committing suicide, so I have an interest from that personal perspective.”

Jon Roth, the Chief Executive Officer of the California Pharmacists Association, describes CURES as currently situated as “suboptimal.” He wants to see a database that is accurate and can combat patients altering identification, and will also not mistakenly deny patients who need pain medications. 


Roth said that the CPhA supports SB 809, but doesn’t think funding options should be limited to fees on licenses. He is also concerned about what he called “uncoordinated enforcement activities” between the Attorney General’s office and the California boards of medicine and pharmacy.

“To me the principle of a prescription drug monitoring program is something we fully support,” Roth said. “We think pharmacists need to be part of the solution to prescription drug abuse in California.”

Waters echoed Roth’s concern with where the funding for SB 809 is coming from.

“We think everybody should be helping out, in particular we think the pharmaceutical companies should be helping out because they’re the ones that make the drugs,” she said.

However, Waters also supports a more robust, effective CURES program. She’d ultimately like to see the ability to share data with other states to track folks crossing state lines to fill prescriptions.

Dr. Itai Danovitch, Chairman of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center in Los Angeles, describes CURES as “clunky” and “cumbersome.” He proposed a larger database that checks for any prescription conflicts, not just scheduled pain pills, to avoid any potentially negative interactions.

For now, Pack is optimistic that SB 809 will pass and a better funded, updated CURES will more effectively track those who doctor shop and physicians running pill mills.

“They’re equally bad,” Pack said. “They really go hand in hand.”

 

Study: Sub-specialty pediatricians in short supply

Published: April 24, 2013 | 1 Comment

Photo: Sean Dreilinger/Flickr

By Rosa Ramirez
California Health Report

California has one sub-specialty pediatrician for every 5,464 children, making it difficult for children with special needs to see an endocrinologist, cardiologist or other medical specialist.

While there’s no ideal ratio—the American Academy of Pediatrics says multiple factors dictate the appropriate figure such as the number of insured and uninsured children, disease burden of the community and presence of academic medical centers—California’s ratio is strikingly low in comparison to other states.

In fact, California’s kids experience more problems obtaining sub-specialized pediatric care than children in any other state, a new UCLA Center for Health Policy Research study has found.

The reasons are multidimensional and so are the recommendations to close the access gap, says Daphna Gans, lead author and research scientist at the center.

“They vary from workforce supply to the different characteristics of the children, such as racial and economic status,” she explained.

The study “Assuring Children’s Access to Pediatric Sub-specialty Care in California,” funded by the Lucile Packard Foundation for Children’s Health,* found persistent disparities to pediatric sub-specialty care by type of insurance coverage, geographic location, language spoken at home and race and ethnicity.

For some of these children, the consequences of such barriers can result in delayed medical care, which ultimate translates to higher medical costs.

(Related: Special needs children struggle to obtain quality health care.)

Some key findings:

• Children with Medi-Cal coverage often receive longer waiting times to see a sub-specialist because of the unwillingness of providers to participate in such program due to low payments, excessive paperwork and payment delays.

• Uninsured children face the most acute access problems. Uninsured children with special care needs in the state are four times more likely to have unmet health care needs.

• The majority of pediatric sub-specialty care is provided at large academic centers typically found in metropolitan areas, leaving many children residing outside such geographic regions with access hurdles. Northern and Sierra counties, which include Shasta, Humboldt and Butte, have a higher sub-specialist-to-children ratio. The Greater Bay Area has the lowest.

• Lack of diversity in pediatric sub-specialty workforce, including those who can communicate with limited-English patients and their families, can also decrease access to sub-specialty pediatric care. The vast majority (64 percent) of children with special care needs are youngsters of color.

California is in the middle of demographic shifts. Hispanics already constitute the majority of school-aged children. Initiatives to diversify the health professional pipeline have been in the works for some time, and some are having some measures of success.

More women going into sub-specialty pediatrics, said Gans.

“Some of the recommendations that we talked were specifically to try to create more diversification of that particular pediatric sub-specialty group,” she said.

An ongoing debate among educators and some in the profession is how to improve workforce incentives, particularly those in the form of loan repayment programs.

Sub-specialty pediatricians must complete three years of general comprehensive pediatrics training after they complete medical school. Those wishing to obtain sub-specialty certification must add three years or more beyond general pediatric training to become certified in developmental-behavioral, cardiology, endocrinology, rheumatology or other specialized training.

Depending on their sub-specialty and type of program, they can spend anywhere from three-to-four additional years beyond general pediatric training, according to American Board of Pediatrics guidelines.

That can translate to delaying entering the workforce. Earlier this year, a group of major health care associations told Congress that any cuts to such loan repayment programs could have an adverse impact.

“Financial concerns, such as debt loan, are a significant factor and a deterrent influencing career choice away from pediatric sub-specialty,” said a letter sent to Congress earlier this year on behalf of some of the largest medical associations in the nation.

“The concern that we see particularly among people in pediatric sub-specialty has become very difficult to get the training, stay in school for so long, then come out making less money than other specialties,” Gans said. “That will continue to jeopardize children’s access to the critical health care services.”

*The Lucile Packard Foundation for Children’s Health is a financial sponsor of HealthyCal.org.

 

In rural California, physician shortages expected to increase

Published: April 23, 2013 | 1 Comment

Photo: Alex E. Proimos/Flickr

By Leah Bartos
California Health Report

In the coming year, millions of currently uninsured Californians will gain coverage under the federal Affordable Care Act — but that does not necessarily mean it will be any easier for them to see a doctor.

As the state prepares for the expected onslaught of newly insured patients, health-care professionals are warning there may not be enough doctors — particularly, those practicing primary care — to meet the increased demand. Some say that the problem will be even more amplified in rural California, which already suffers a physician shortage and dwindling workforce, as the majority of rural physicians nears retirement and recruitment of new doctors lags in replacing them.

“The country family docs are getting old and retiring, and the younger folks don’t necessarily want to come out the remote areas,” said Dave Jones, board president of the California State Rural Health Association.

Jones, who is also CEO of the nonprofit Mountain Valleys Health Centers in northeastern California, said that it’s always been challenge to recruit young physicians to replace their predecessors. One factor, he said, is a difference in lifestyle choice.

“Country doctors doing family practice is kind of a 24/7 job,” Jones said. “What we find is that many of the young docs go into specialties because they do get paid more, their hours are more regular and they have a better lifestyle.”

Indeed, the trend toward doctors practicing medical specialties has been seen statewide, with only about a third of active physicians practicing primary care. As for the physician workforce as a whole, the state is also experiencing an uneven distribution, with 60 percent of doctors practicing in only five counties, as reported by Association of American Medical College

“It has been an issue for a long time; with the Affordable Care Act coming in and looking more toward wellness and primary care, it’s going to make it even harder,” Jones said.

While Jones applauds the health reform’s increased emphasis on primary and preventative care, he cautions it will be for naught if the workforce shortage is not taken into account.

“I certainly think the intent is really good — and that’s to promote wellness, keep people well and keep them out of the hospital, which is better for all of us,” Jones said. “All of that is good, it just means that we need more primary care providers to do that.”

Of course, not all doctors-in-training are shying away from the rural areas. Some, in fact, prefer it.

Alexa Calfee, a second-year medical student at UC Davis, said she finds rural medicine to be the most exciting. She is enrolled in the UC’s Rural-PRIME (Programs in Medical Education), which was established at UC Davis to help alleviate health disparities in rural California.

“Family practice, especially in a rural area, is the frontline of medicine. You see a wide variety and you need to work with people to help solve their problems [that] can range from an agricultural injury to an injury in the wilderness to chronic care conditions,” said Calfee. “The variety is huge and you could be the only doctor for hundreds of miles. I just think that’s an exciting place to be.”

Calfee, herself a native of rural Yolo County, ideally would like to be a general practitioner in a small rural clinic. She knows she probably won’t make as much money as doctors in urban areas or those who go into specialties, but hopes it ultimately won’t impact her decision or ability to pay of her student loans after medical school.

In California, patients living in rural areas are less likely to have private insurance than their urban counterparts. And while many of them are covered by Medi-Cal, the state’s insurance program has an infamously bad track record when it comes to reimbursements. But soon some of that burden may be lifted, with the federal government footing the bill for the state’s insurance program for the next three years under the Affordable Care Act. Some are hoping better reimbursements will create more incentive for doctors to work in rural areas.

“It’s not a shock that there’s a provider shortage in a place where there’s 25 percent uninsured patients,” said Anthony Wright, executive director of Health Access, a healthcare consumer advocacy group in California. “If you create a lot more paying customers by getting them insured…the hope is that the market will adjust in terms of having more [doctors] there.”

Wright also pointed out that though the newly insured patients are becoming more visible, the need for medical services has always been there.

“It’s not like the newly insured don’t exist in our health system already. It’s not like they’re suddenly entering the health-care system from nowhere,” Wright said. “[They] are getting care, but in the least efficient, most expensive way possible.”

In rural California, the expense also translates to poorer health outcomes than in urban areas, according to studies cited by the California State Rural Health Association. For instance, patients in rural areas were more likely to have suffered strokes, heart attacks, and diabetes than their urban counterparts; smoking and alcoholism are more common; and a higher portion of rural residents have self-reported suffering depression, stress, and other mental issues, as well as rating their overall health as poor.

“The more I learned about rural health, the more I saw that this is a huge problem in the state of California and it’s not being addressed,” said Gaber Saleh, who is also a second-year medical student in the UC Davis Rural PRIME program.

Saleh wants to practice in rural areas because that’s where he sees the greatest need. He said the health disparities and access issues in rural California remind him of problems he observed visiting Yemen, where his parents are from. “I can’t help the people in Yemen, but I can do something about the problems here,” said Saleh, who was born and raised in Contra Costa County.

In addition to needing to increase the primary care workforce in rural areas, Saleh says the state needs to work on diversifying its physician pool, not only in terms of ethnic, but also socio-economic backgrounds.

“It makes a big difference when the person treating you looks like you — even beyond that, it’s not just about having the same skin color as you, but at least understanding where you’re coming from,” he said.

And as far as the likelihood of earning less money than a specialist in an urban practice?

“It doesn’t bother me at all. As a physician you make a great salary” — which Saleh estimated to be $150,000 to $180,000 a year for primary care physicians — “When did that become chump change?”

Even with the cost of medical school, Saleh dismisses monetary incentives for recruiting and retaining physicians in rural areas.

“The idea now that’s being thrown around is you increase the salaries of primary care physicians,” he said. “Is that really the direction we need to go though? Aren’t we just adding to the cost of health care rather than bringing it down?”

 

Drop-out rate contributes to jobs-education mismatch

Published: April 21, 2013 | No Comments

By Daniel Weintraub
California Health Report

As California heads into a future dominated by technology, a skilled workforce is going to be more important than ever. But despite recent gains, the state is still not producing enough educated workers to fill all the jobs that are open — a cruel paradox in a time of persistently high unemployment.

Only 78.5 percent of the students who started high school with the class of 2012 left with a diploma four years later, according to the latest figures released by the state Department of Education, up from 77.1 in the class of 2011.

About 13.2 percent were officially listed as drop-outs in the most recent year, but that does not include students who have been in high school longer than four years without graduating, students who left after four years without a diploma, and special education students who do not graduate.

The drop-out number also does not account for kids who quit school before they ever reach 9th grade.

State schools Supt. Tom Torlakson welcomed the latest numbers, saying they show steady improvement. But he said the drop-out figures are still too high, especially given the gap between white and Asian-American students, who graduate in numbers higher than the statewide average, and blacks and Latinos, who drop out more often.

“We have a long ways to go in all of these sectors,” Torlakson said. “We’d like to see the statewide average move up to 80 to 85 percent, to 90 percent. We’d like to see this achievement gap close even more rapidly.”

As an aside, the state has made some important progress lately in tracking these numbers. Until recently, when a student left a school or a district, there was no way to know whether he or she had enrolled elsewhere, making graduation and drop-out numbers unreliable.

But beginning in 2009, students were assigned unique identifying numbers that follow them from kindergarten through graduation. That’s made it much easier to track with accuracy what happens to a student who leaves a school before completing 12th grade.

There are still flaws in the system, especially when it comes to assessing student performance at individual schools and districts. When struggling students transfer from a regular school to a continuation school run by a county office of education, for example, they are not counted as drop-outs from the original campus, even if they quit school altogether a few weeks later. There’s also no way to be sure that schools are accurately counting the number of students reported as transferring to schools in another state.

But the numbers are a lot more accurate than they used to be. And they are leading to increased focus on improving the achievement of minority students.

The Latino graduation rate for the class of 2012 was 73.2 percent. For African-Americans, it was 65.7 percent.

Pamela Short Powell, president of the California Association of African American Superintendents and Administrators, said recent gains – the graduate rate for black students climbed 2.9 percent last year – are welcome but not enough. California is trying to reach a national goal of graduating 90 percent of students by 2020, and Short Powell notes that African American numbers will have to improve at a faster rate than they have been to get there.

“There’s no doubt that African-American young people are still lagging behind their peers,” she said.

And this isn’t just about numbers and goals. Lives are at stake. High school drop-outs are four times more likely to be unemployed as college graduates, according to the National Drop-out Prevention Center, and, on average, high school graduates earn $143 more per week than drop-outs. Those who leave high school without graduating are also more likely to be on public assistance, and 82 percent of prison inmates are high school drop-outs.

There are also broader concerns, for society.

A study of job openings and education by the Brookings Institution last year found some eye-opening patterns. It turns out that in many places in California and elsewhere, there were more job openings than there were unemployed people. The problem lay in a mismatch: those looking for work didn’t have the education to fill the jobs that were open.

In Modesto, for example, there were 10 job openings for every unemployed worker with a bachelor’s degree, and in Bakersfield there were 11.5 job such openings. That was 10 times the number of job opportunities available for every unemployed worker with just a high school diploma, let alone the high school drop-outs.

Another way of looking at the same issue is to examine the gap between the number of jobs requiring a college education and the number of workers who have one. San Jose led the nation in the percentage of job openings requiring at least a bachelor’s degree, at 56 percent, but only 35 percent of unemployed workers in that area had one. In Los Angeles-Orange County metro area, 44 percent of openings required a degree, while just 29 percent people seeking work had graduated from college.

But too many students can’t even dream yet of a college degree. A high school diploma is the problem. And the problems that got them there started long before high school.

One of the big indicators of future success is the ability to read by third grade. After that point, students start using their reading skills in social studies and science, and if they are struggling with reading, that handicap puts them further behind in the other subjects too. A similar indicator is a student’s mastery of algebra by 8th grade.

Another red flag is chronic absenteeism, when students miss more than 10 percent of instructional days. In some low-income communities, kindergarteners are missing school nearly 20 percent of the time.

“Without intervention,” Torlakson said, “a child may lose up to a year of education by the time they are in 8th or 9th grade. If you are absent that much you are falling behind.” Eventually, frustration sets in and students who can’t keep up simply give up, putting themselves, in too many cases, on a road to a lifetime on the edges of mainstream society.

The state and local school districts have programs aimed at all of these issues, and it is safe to say that nearly every district in the state is focused on closing the achievement gap – and the graduation gap — among the racial and ethnic groups. Their success or failure will play a huge role in shaping what kind of state California turns out to be over the next quarter century.

Daniel Weintraub has covered public policy in California for 25 years. He is editor of the California Health Report at www.healthycal.org

 
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