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IN THE SPAN OF ABOUT two years, the number of patients visiting loma linda medical center from inland Riverside and San Bernardino Counties doubled, while the number visiting from hemet and san Jacinto rose by nearly four-fold. looking to help medical care keep pace with one of the country’s fastestgrowing regions, loma linda university is taking part in two joint ventures and expanding into riverside county with a new hospital in murrieta and a medical plaza in Beaumont.
Opening for full business in october, highland springs medical plaza is a joint venture of LLU, redlands community hospital and Beaver medical group. serving an area north of the medical center and as far east as yucaipa, the new facility includes a medical office building, an outpatient surgery center, urgent care capabilities and other medical and surgery programs. its ancillary services include imaging, laboratories, and physical therapy.
The LLU medical center-murrieta is a 106-bed facility that is scheduled to open in early 2011 to serve murrieta’s neighbor communities around the intersection of I-15 and I-215. a collaborative effort with physicians group of murrieta, the medical center will offer interventional cardiovascular services, obstetrics, pediatrics, urology and orthopedics, according to the university. the medical center will be outfitted with surgical suites, a laparoscopic surgery center, an imaging center, emergency room services and general and acute-care services.
It hasn’t worked out that way. The old studies expected a shortage of primary care physicians, which is what we see, but specialists are in short supply too. Relying on these models, many medical schools scaled back or held the number of new doctors constant. In rural Southern California, the number of specialist physicians available to serve the population is well below that of urban areas, and several factors exacerbate the problem, including population growth, low reimbursement, and difficulties recruiting and retaining new doctors.
It’s not all gloom and doom, though. Here we look at what’s happening in rural Southern California and why, and we explore a few ideas for getting rural people the kind of medical attention that they need. There are also some exciting developments just down the road, including telemedicine, medical school-loan payment programs and more.
Shrinking Supply, Growing Demand
“Schools in the mid-’90s and early 2000s were not
increasing enrollments at all—it was about as flat as it could
be, when you looked out across the country,” says Roger Hadley,
MD, dean of Loma Linda University School of Medicine. For
about 15 years, the number of medical schools in the nation
stayed constant at 125, while enrollment held at around 15,000.
Estimates predicting a physician surplus were often based on health maintenance organization operations, and some researchers now argue that many estimates didn’t take out-ofnetwork care seriously. The public also reacted negatively to the more restrictive nature of some HMOs, throwing off-kilter estimates of healthcare use. To these factors, Hadley adds that young female physicians seem more likely to take significant time off the job to have children, compared to their counterparts who graduated in the 1970s and 1980s.
That phenomenon is certainly familiar to California physicians, although increased medical service utilization is sometimes a touchy subject. And it’s not just medications—for example, it’s now possible to get a gall bladder removed and return to work within two days. People once bore the pain of gall stones to avoid big incisions and long recovery times.
In addition to any expansion of the overall healthcare market, the population of rural Southern California has demonstrably exploded, and may well continue to do so. Riverside County’s population is now about 2.1 million, a 36-percent increase from 2000. In that time, San Bernardino grew 18 percent to 2 million, while the population of Imperial increased 15 percent to 165,000. By 2050, Riverside and Imperial Counties are expected to double in size, while San Bernardino is expected to grow to 3.7 million. In Imperial County, for example, retirees from nearby Yuma, Ariz. have increasingly settled on the California side of the border. “We’ve picked up a lot of doctors,” says former Imperial County Medical Society president Travis Calvin, MD, “but we haven’t picked up anything proportionate to the growth of the population.”
San Bernardino and Riverside are best characterized as a mix of urban or suburban development to the west and rural and remote areas to the east. The recent growth of the Victorville-Hesperia area, near where Riverside County Health Officer Eric Frykman, MD, used to work, has resulted in a population of more than half a million, and the area is still short of cardiac, vascular and neurosurgeons. “How many spots in America have 500,000 people and no local access to these surgical subspecialists?” Dr. Frykman asks rhetorically. “The answer is there are none.”
He attributes the low density of specialists in the remote parts of Riverside and San Bernardino mostly to the usual lack of infrastructure and a patient base too small to support physician practices and facilities. “There is a lack of physicians in these counties, in general,” he notes. “But when you get into the rural or remote areas, the dearth of physicians gets worse. [The situation] is more anecdotal than anything, but if you look at surgical specialties or specialties like oncology and nephrology, you’re not going to find many of them, because they tend to be based in He attributes the low density of specialists in the remote parts of Riverside and San Bernardino mostly to the usual lack of infrastructure and a patient base too small to support physician practices and facilities. “There is a lack of physicians in these counties, in general,” he notes. “But when you get into the rural or remote areas, the dearth of physicians gets worse. [The situation] is more anecdotal than anything, but if you look at surgical specialties or specialties like oncology and nephrology, you’re not going to find many of them, because they tend to be based in large significant hospitals with lots of ICU beds. Who’s going to be doing open-heart surgery in the middle of the desert?”
According to the California Medical Association, about 70 percent of physicians in the state are at least 45 years old, so the retirement rate is only exacerbating shortages. California imports most of its doctors from outside the state because in-state medical schools can’t produce enough graduates to fill open slots.
All this adds up to busy, busy physicians. In rural San Bernardino, this gave Loma Linda University Medical Center a hard time, when it came to recruiting—and until recently, it was the single biggest headache for Roger Hadley, MD, vicepresident of medical affairs for the university and dean of the medical school. But with the economic slowdown came a surprising up side. “The recession actually helped us a bunch—physicians are now interested in coming here and working, because their opportunities are just not as broad as they were,” he says. Before the recession, his hardest specialties to fill were orthopedics, radiology, transplant surgery, and cardiology. Now Loma Linda is most in need of hospitalists, primary care doctors and general internists, but the need isn’t as acute as it had been.
The Hard Numbers
All in all, California has about 66,480 MDs who practice
patient care at least 20 hours a week, and if you include an
estimated 2,980 doctors of osteopathy, the final total is about
69,460 doctors. The MD numbers are the most reliable statistics
on physicians practicing in the state—they come from a
new report published by the California HealthCare Foundation,
based on data collected by the Medical Board of California up
to June of last year. The DO estimates are based upon data
from the American Medical Association’s Physician Masterfile.
For every 100,000 state residents, there are around 63 primary care physicians and 118 specialists—enough to satisfy the Council on Graduate Medical Education’s estimated minimum needs of 59 primary care and 105 specialist physicians per 100,000. But when you take the data apart geographically, it’s clear that those needs are often unmet, particularly in rural counties.
The three rural counties in Southern California Physician’s territory—Imperial, San Bernardino and Riverside Counties—are medically short-handed by the COGME standard of 164 active physicians of any kind per 100,000 residents. Looking only at the data for MDs, which are most accurate, Imperial has 80 active physicians per 100,000 residents, while San Bernardino has 121 and Riverside has 99. Larger counties typically attract more physicians per capita, but as the CHCF report notes, Riverside is the only county in the state with more than 1 million residents and fewer than 100 physicians per 100,000 people. In contrast, large, urban Orange County—whose population exceeds 3 million—has 185 active MDs per 100,000 people.
When you break the data down by specialty, the rural-urban disparity only grows. About 22 primary care MDs in Imperial serve 100,000 people, while San Bernardino boasts twice that density and Riverside comes in-between with 36. Orange County and Los Angeles County have 64 and 58 primary care MDs per 100,000 people, respectively. Ventura County, which is not exactly rural or urban, has 56 primary care MDs per 100,000 people. Note that only Orange fulfills the COGME estimated need.
Beyond primary care, the situation gets much more complicated. Imperial County has about 59 specialists per 100,000 people—far below the COGME recommendation of 105. San Bernardino’s comparable rate is 77, while Riverside’s is 62. The three rural Southern California counties have startlingly few doctors in particular specialties, too. For example, former ICMS President Dr. Calvin is the only neurosurgeon in Imperial County.
The Promise of Telemedicine
When it comes to alleviating rural problems with access to
medical care, telemedicine has a lot of hope pinned to it. “It’s a
way of rendering medical care to patients who live too far from
a major medical center or have no means to get there,” says Ira
Lott, MD, the UC Irvine School of Medicine associate dean for
telemedicine and a pediatric neurologist. The physicians at UC
Irvine have been practicing telemedicine since around 2001, with
about 5,000 consultations under their belts, mostly in psychiatry
and neurology. Currently, the school’s telemedicine serves
regional centers for people with developmental disabilities in
both rural and urban areas in the state. Perhaps just as important,
the UC Irvine School of Medicine is educating the next generation
of doctors—some 400 are enrolled at any one time—with
the skills to provide remote care.
As for the future of this technology, Dr. Lott says there’s now a big push in California to expand the scope and reach of telemedicine. “The University of California has received a grant from the Federal Communications Commission that’s going to fund an infrastructure backbone for telemedicine for rural clinics scattered up and down the spine of California,” he says. To date, more than 800 rural clinics have submitted letters of agency to take part in the effort. Also, state voters passed Proposition 1D in 2006 to fund medical education generally, but also for telemedicine specifically. As a result, telemedicine is a regular part of a California medical education.
Another such effort at UC Irvine is the California Institute for Telecommunications and Information Technology—or CalIT2. That effort is trying to develop the next generation of technology to render telemedicine services. “They’ve come up with a new module for this, in which digital data can be uploaded, as well as video telemedicine,” explains Dr. Lott.
Telemedicine will extend the reach of specialty physicians, particularly those who rely primarily on observation, such as neurology, and new peripheral devices allow otolaryngologists, cardiologists and others to use it too. “But if the data that you wanted to obtain was solely based upon, for example, palpating the abdomen, that would probably be more difficult to do by telemedicine,” says Dr. Lott. “It would be an exception, though. As far as the doctors are concerned, many more are interested in using telemedicine to provide services, but there is still a need to educate physicians.”
Asked how long it will take for telemedicine to become widespread, and to fill some of the gaps in rural healthcare access, Dr. Lott cites a surprisingly short five years.
Getting—and Keeping—Students
Currently, the state produces somewhat more than
5,700 MDs and DOs, with modest growth over the years.
Still, as mentioned above, California has to import much
of its physician workforce. So how do you encourage new
medical school graduates to work in a rural setting? “It’s
recruitment, it’s who we accept into medical school,” says
Loma Linda’s Dr. Hadley. He proudly notes that his School of
Medicine is in the top 75th percentile of schools whose graduates
work in rural areas, and it’s among the top ten schools
graduating family medicine doctors.
Loma Linda University School of Medicine also offers rotations in rural areas, and once students see the value of their work first hand, they will often opt for another such slot. Asked what else would encourage new graduates to head for more bucolic settings, Dr. Hadley says scholarship programs and loan repayment programs are probably at the top.
But the limited timeframes of those efforts can prove to be a drawback. “You may get physicians to work in a more remote setting for their time period” with rotations and loan repayment programs, says Dr. Frykman, the Riverside health officer, “but when their time is up, the evidence shows that physicians typically don’t stay in the area.” That’s partly because even with loan repayment, rural salaries are still subpar, when compared to many urban settings. But Dr. Hadley says the first step to attracting doctors is simply a matter of exposure. “The best retailers in the world will say, ‘Just get someone in my store, and I’ve got a chance to sell them something.’”
This is where the UC Davis School of Medicine’s Rural- PRIME effort plans to step in. A five-year MD and master’s program, Rural-PRIME is aimed at high-performing students who themselves come from rural backgrounds and are interested in making a difference in those communities. The school describes the program as focusing on “team medical practice, advanced information and telecommunication technologies, and evidence-based medicine.” In particular, Rural-PRIME emphasizes telemedicine.
New capacity is also on the way. By 2012, the UC Riverside School of Medicine should open its doors and graduate about 50 students a year, and by 2017, it should be producing about 100 doctors a year. Medical school spokesperson Kathy Barton says the new educational facility will be focused on providing services for its immediate region and the school’s underserved areas, including rural parts.
Attracting Doctors
When it comes to bringing
physicians to rural Southern
California, the best solutions
can be pretty expensive and
time consuming. “You’ve got to
have the infrastructure to support
them,” says Dr. Frykman,
the Riverside County health
officer, “and then you have to
have a mechanism by which
these people can be reimbursed.”
Without a population to support a specialist’s salary at even 20 percent below the median level, physicians are going to have a tough financial go of it, regardless of how wellmeaning they are. “It’s going to be really hard to fund a neurosurgeon just on Medi-Cal rates, and the elderly population that might be on Medicare doesn’t live in Mecca or Thermal,” says Dr. Frykman. In 2007, about 28 percent of Imperial County residents relied at least partly on lowpaying Medi-Cal, while 18 percent of San Bernardino residents and 14 percent of Riverside residents also did so, according to state statistics.
“We have exactly 71 percent who qualify for Medicare-Medi- Cal or Medi-Cal alone,” says Dr. Calvin, the Imperial County neurosurgeon. “As a consequence, the other guys around here are so overburdened that they have a hard time ever getting to the Medi-Cal people, and a lot of them just refuse to see them. That’s really a shame.”
“The community needs to recognize the cost of having healthcare,” says Loma Linda’s Dr. Hadley. In some ways, it has. California’s Steven M. Thompson Loan Repayment Program will repay as much as $105,000 of medical school debt, for doctors who agree to serve for three years an underserved area. So far, that program has placed nearly 100 doctors across the state, and thanks to a new law by Assemblyman Hector De La Torre (D-South Gate), it will have guaranteed funding stemming from a $25 fee added to the Medical Board of California’s usual license and renewal fees. A bill currently in front of the state Senate, Senator Denise Moreno Ducheny’s (D-San Diego) SB 606, seeks to expand the program to DOs, in addition to MDs.
On the federal level, there is the National Health Service Corps, which also helps repay the debts of doctors who serve the underserved. But the NHSC focuses on primary care physicians who decide to work for public or non-profit organizations in official health-professional shortage areas for two to four years. The NHSC will repay as much as $120,000 of medical school debt.
Family pressures are one of the main forces that keep some doctors from working outside the cities, says Dr. Calvin. The distance to cultural offerings, such as concerts, the ballet, shopping and all the rest can persuade a doctor’s spouse to push for a different locale. What else? “The weather turns a lot of people off—if they’re down here in the summer, it’s hotter than blue blazes, but nine months of the year, it’s an ideal climate,” says Dr. Calvin.
But Imperial and the other rural counties can play to their strengths. For a young family, the standard of living and relative safety are hard to beat, and these areas often recognize the importance of offering children’s activities. And despite a reputation for being remote, rural Southern California is quite diverse. “We’ve got every ethnic group in the whole world,” notes Dr. Calvin, “and I don’t know of any really serious interethnic group problems—I think that’s really a plus about the Imperial Valley.”
Change is in the Air
When it comes down to it, the people most affected by the
rural physician supply are rural residents themselves. “It’s difficult
to measure, and what the lack of primary or specialty
care access contributes to chronic disease and poor health
is really hard to tease out,” says Dr. Frykman. “That’s partly
because the rates of all these things are going up; there are
many societal and environmental factors that are pushing this
stuff to higher rates.”
When it comes down to it, the people most affected by the rural physician supply are rural residents themselves. “It’s difficult to measure, and what the lack of primary or specialty care access contributes to chronic disease and poor health is really hard to tease out,” says Dr. Frykman. “That’s partly because the rates of all these things are going up; there are many societal and environmental factors that are pushing this stuff to higher rates.”
