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Doctors needed as health care reform approaches

BY STEVEN MAYER AND JOHN GONZALES, Californian staff writer; California HealthCare Foundation Center for Health Reporting senior writer | Saturday, Aug 21 2010 02:00 PM

Last Updated Saturday, Aug 21 2010 02:00 PM

Dr. Katherine Schlaerth loves her work, but there's not a lot of downtime at the crowded nonprofit Family Health Center in central Bakersfield.

"There are no lulls around here," Schlaerth said with a tired smile as she double-checked a patient's chart before moving to her next appointment.

Despite her job satisfaction, when Schlaerth contemplates the state of health care in Kern County and other areas of the state, her outlook darkens.

"I do worry about what's going to happen in the future," she said.

There's a lot to worry about.

Over the next few years, an estimated 62,000 uninsured patients in Kern are expected to come looking for a "medical home" -- a primary care doctor with all the fixings -- offered up by federal health care reform.

A multi-year pilot project known as the Kern Medical Center Health Plan has already enrolled about 5,500 formerly uninsured low-income patients in Kern over the past three years. Financed by state and federal funds, that experiment has been judged a success by county officials and state experts. It will soon be replaced by a new, much larger plan that will also route federal dollars into managed care for low-income, documented adults.

But Schlaerth and other health care professionals wonder where all the new patients will go -- and who will step up to be their doctors.

"I'm panicked," said Carol Sorrell, chief executive of Kern Health Systems, a local Medi-Cal administrator that will manage the member services, accounting, marketing and several other responsibilities under the new plan.

Sorrell said it's already difficult to find a sufficient number of care providers for the organization's approximately 115,000 members. Signing up enough new doctors -- both primary care and specialists -- to take on tens of thousands of new patients is a staggering assignment.

"Kern County is a medically under-served area, both for primary and specialty care," Sorrell said.

"We live it," she said of Kern's physician shortage. "Every day."

DOCTORS: PLEASE COME TO KERN

An assessment of physician numbers published last year by the non-partisan California HealthCare Foundation (the non-profit foundation funds the Center for Health Reporting, which is a partner on this project) found that Kern County had 45 active primary-care doctors per 100,000 residents in 2008, the most recent year the data was available.

The ratio in Fresno County is about the same, at 46 per 100,000. San Joaquin Valley counties as a rule have a much thinner supply of doctors than most of the state's coastal counties. Kern also fell short on its supply of specialists -- such as neurologists and orthopedists -- at 67 per 100,000 population.

To put these numbers in context, the Council on Graduate Medical Education, a research organization funded by the federal Department of Health and Human Services, estimated the minimum number of primary care physicians to ensure "adequate supply" at 60 to 80 per 100,000 population, significantly higher than Kern's 45. Specialists should number between 85 and 105, it estimates.

"We don't have nearly enough physicians to provide medical homes or to cover the need for specialty care," said Paul Hensler, chief executive of Kern Medical Center, Kern County's public hospital.

It gets worse.

"I can't emphasize this enough," said Clinica Sierra Vista CEO Steve Schilling. "Many of the 45 per 100,000 don't see all comers."

He cites as evidence that many physicians routinely reject Medi-Cal recipients and other patients who don't have private insurance. There has been "a doctor flight out of poor America and into upper-middle class America," Schilling said.

"They don't see our patients," he said. "In our communities."

A 2008 California HealthCare Foundation analysis appears to support Schilling's complaint. The study, based on various polls of physicians across the state, found that only 54 percent of primary care doctors in California accept new Medi-Cal patients.

But Schlaerth, who spends some of her time each week training young residents in Southern California, cautioned that nothing will be fixed until the underlying causes of such provider shortages and so-called "doctor flight" are addressed.

"Medical school has gotten so expensive," she said, leaving many young doctors heavily in debt and pushing them toward more lucrative locations and areas of specialty.

We must increase incentives -- and remove barriers -- to bring more doctors to under-served areas, she said.

PROACTIVE VS. REACTIVE CARE

When area residents can't find a "medical home," shorthand for a doctor's office or clinic that knows the patient and has ready access to records and medical history, they often do not receive adequate, sustained care for chronic conditions such as diabetes or high blood pressure.

As a result, their care becomes reactive rather than proactive, Schilling said. It also becomes much more expensive, because patients wait until they are sicker, head to emergency rooms and require more frequent hospitalizations.

Bakersfield resident Juanita Kelley worked for years as a certified nursing assistant. But when her arthritis forced her out of full-time nursing, private health insurance proved way beyond her financial reach. In fact, she had trouble affording medical care for most of her working life.

Now 54, Kelley said she visited the ER three times in recent years because her diabetes was out of control.

"It was terrible," she said. "It would take most of my paycheck just to take care of my prescription medicines."

Everything changed, Kelley said, when she enrolled in the KMC Health Plan earlier this year.

After several appointments with Dr. Schlaerth at Family Health Center, one of the clinics in the heath plan's provider network, Kelley's diabetes has become more manageable and she's getting attention for her arthritis.

"This program saved my life," Kelley said.

'FEEDING THE TIGER'

Schlaerth said the severe economic downturn has left many of the clinic's patients out of work and some without private health insurance for the first time. The bureaucracy of federal health care reform was of less concern to her than the immediate needs of her patients.

"I look at it as a way to provide health care for people who need it," she said.

Hensler and Sorrell know how tough it's going to be to overcome the challenges Kern County faces, and they're already developing strategies to address them.

Fortunately, some provisions in health care reform are designed to deal specifically with the expected surge in demand. Proponents hope that planned increases in reimbursement rates for doctors treating Medi-Cal patients will help broaden the provider network. And federally-funded financial incentives for doctors to practice in rural and under-served areas are designed to make it more attractive for physicians to treat patients in communities such as the Kern River Valley, Frazier Park, Arvin and southeast Bakersfield.

Schilling, who believes his network of clinics provides health care to the poor much more efficiently than the county, remains hopeful but skeptical about whether the new initiative can succeed as a model for health care reform.

So far he has not committed his network.

"If we don't have enough entities and organizations that host primary care access points, then reform will not work," he said.

If the new county-run initiative is truly supposed to build a bridge to health care reform, Schilling said, it must be lean and mean enough to increase the number of clinics and the number of providers.

If it's not, he said, "This is not the bridge we want to build.

"It will simply feed the tiger for a few extra years."