Research Report pipeline of trainees in California. The report finds that California’s Primary previously identified deficits in California’s primary care Care Workforce: workforce persist and will be exacerbated in the coming decade because large percentages of MDs and NPs are Current Supply, reaching retirement age. Characteristics, and Forthcoming reports in this series will forecast the future supply and demand for primary care clinicians and assess Pipeline of Trainees primary care workforce development initiatives in other states. Collectively, these reports will enable stakeholders to assess the adequacy of the current primary care workforce, by Janet Coffman and Igor Geyn and Kristine anticipate future gaps in the primary care workforce, and A. Himmerick, Healthforce Center at UCSF identify effective policies for addressing these needs. February 2017 Key Points: Supply and Characteristics of Clinicians EXECUTIVE SUMMARY: Supply Introduction ! Rates of growth have varied widely across the Health care stakeholders are concerned that the supply, four professions and between primary care and distribution, and demographic characteristics of primary specialist clinicians. care clinicians in California are not adequate to meet the state’s needs. In recent years, this concern has stemmed o Growth in the DO, NP, and PA workforces in largely from the expansion of Californians’ access to health California outpaced the rate of growth of the insurance under the Affordable Care Act (ACA). The MD workforce from 2004 to 2016. (MD 36%, expansion of eligibility for Medi-Cal and the establishment DO 141%, NP 75%, PA 98%). of Covered California, the state’s health insurance exchange, have resulted in a large increase in the number of ! While MDs make up the greatest number of Californians with health insurance. Although the fate of the licensed clinicians, only a fraction of them ACA is uncertain, other sources of concern about primary provide primary care (36%). Among MDs care clinician supply in California persist, including practicing more than 20 hours per week, the population growth, aging of the population, expanding same proportion are in primary care. burden of chronic disease, and the needs of low-income o The percentage of PAs in California who people and racial/ethnic groups that have been historically provide primary care is also small (22%). underserved by the health professions. This report presents the most current information on the o In contrast to MDs and PAs, approximately supply of MDs, DOs, NPs and PAs who provide primary 60% of DOs and 50% of NPs provide care in California. In the absence of a uniform dataset on the primary care. four professions, data from multiple sources were aggregated and analyzed to examine the supply and employment patterns of primary care clinicians and the © 2017 Healthforce Center at UCSF California’s Primary Care Workforce: Current Supply, Characteristics, and Pipeline of Trainees 2 Source: California Department of Consumer Affairs, 2016; special request, private tabulation. Medical Board of California, Survey of Licensees, May 2015; private tabulation of active MDs. Medical Board of California, Survey of Licensees, May 2015; private tabulation of primary care and specialty practice in 2016. American Osteopathic Association, Osteopathic Medical Profession Report, 2014. J. Spetz, E. Fraher, Y Li, T Bates. How Many Nurse Practitioners Provide Primary Care? National Commission on Certification of Physician Assistants, Profile Data 2016, special request, private tabulation. See technical appendix for additional detail. ! The ratio of primary care physicians to ! Only two regions of California (Greater Bay Area population in California is similar to the national and Sacramento Area) have ratios of primary ratio, but the ratios of NPs and PAs to care physicians per population above the population are lower (35% lower for NPs and minimum ratio recommended by the Council on 16% lower for PAs). Together, these dynamics Graduate Medical Education (60 primary care contribute to the structural shortage of primary physicians per 100,000 population), indicating care clinicians. that the primary care physician supply in most regions of California is not adequate to serve the o The low ratios of NPs and PAs to population population. in California may represent an opportunity to expand employment of NPs and PAs in the ! Two regions (Inland Empire and the San Joaquin state. Valley) have ratios of primary care physicians to population that are below the ratio of primary Geographic Distribution care physicians to beneficiaries that the California law requires managed care plans to ! The distribution of primary care clinicians varies meet (50 primary care physicians per 100,000 widely by region in California. population). o NPs and PAs constitute a larger share of the primary care workforce in rural regions of California than in urban regions. © 2017 Healthforce Center at UCSF California’s Primary Care Workforce: Current Supply, Demand, and Pipeline of Trainees 3 ! The aging of the family physician workforce is Demographic Characteristics especially worrisome. Nearly half of family physicians (44%) are age 55 years or older. ! One third of physicians and NPs in California are age 55 years or older, raising concerns about ! Conversely, only 16% of PAs are age 55 years or reductions in the capacity of the workforce in older. coming years due to retirement or decreased patient care hours. All Physicians* MDs in Primary Care 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% < 35 35-44 45-54 55-64 ≥ 65 < 35 35-44 45-54 55-64 ≥ 65 Age Age All NPs All PAs 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% < 35 35-44 45-54 55-64 ≥ 65 < 35 35-44 45-54 55-64 ≥ 65 Age Age Source: American Community Survey, Public Use Microdata *Includes allopathic and osteopathic physicians and surgeons Sample, 2015, private tabulation. Medical Board of California, Survey of Licensees, May 2015. May not sum to 100% due to rounding. © 2017 Healthforce Center at UCSF California’s Primary Care Workforce: Current Supply, Characteristics, and Pipeline of Trainees 4 ! A smaller percentage of physicians in California American or Latino, while only 13% of are female (34%) relative to their NP (92%) and primary care physicians, 19% of all NPs, PA (64%) counterparts. and 26% of all PAs are African American or Latino. ! There are wide disparities between the diversity of the California population and the diversity of all medical clinicians. o The California population is 44% African Source: American Community Survey, Public Use Microdata Sample, 2015, private tabulation. Medical Board of California, Survey of Licensees, May 2015; private tabulation. Geriatricians included with General Internists and General Practitioners included with Family Physicians for the purposes of these calculations. Proportions may not sum to 100% due to rounding. MBC estimates do not include non-respondents (12% for this question in the survey). € Includes allopathic and osteopathic physicians and surgeons. * Includes all PAs and NPs in primary care and other specialties Practice Settings o Family Physicians are more likely to be in solo practice than General Internists (26%), ! National trends over the past three decades General Pediatricians (15%), and indicate that the percentage of physicians in Obstetrician/Gynecologists (28%). solo practice has decreased ! 14% of primary care physicians in California o 25% of primary care MDs in California are are members of the Permanente Medical in solo practice. Group, including: 13% of Family Physicians, 16% of General Internists, 11% of General © 2017 Healthforce Center at UCSF California’s Primary Care Workforce: Current Supply, Demand, and Pipeline of Trainees 5 Pediatricians, and 17% of ! Within California, employed primary care Obstetrician/Gynecologists in the state. physicians earn less in hospitals and outpatient care centers compared to their counterparts in ! 9% of primary care physicians in California ambulatory health care services and practice in federally qualified health centers, physicians’ offices. other community clinics, and public clinics Sources: Association of American Medical Colleges, FACTS Table B-2: Total Graduates by U.S. Medical School and Sex, 2015; American Association of Colleges of Osteopathic Medicine, Graduates by College & Gender 2015; Physician Assistant Education Association Program Surveys 2015, private tabulation; American Association of Colleges of Nursing, Research and Data Services, 2016, private tabulation. including: 12% of Family Physicians, 5% of General Internists, 11% of General o Conversely, NPs and PAs earn the most in Pediatricians, and 3% of hospital settings and earn less in Obstetrician/Gynecologists in the state. ambulatory health care services and physicians’ offices. ! PAs are more likely than NPs to practice in physician offices (32% versus 17%), while NPs Primary Care Trainees – Training Programs are more likely than PAs to work in hospitals (39% versus 34%). ! In 2015, there were 2,575 graduates of MD, DO, PA, and NP training programs, including Earnings 1,080 MDs, 448 DOs, 692 NPs, and 355 PAs. ! Earnings data are available only for primary care clinicians who are employees. This is an o MD, DO, and PA graduates are predicted important limitation for physicians because a to increase with the opening of 2 new substantial proportion of them are in solo medical schools (1 MD and 1 DO) and 4 practices or small partnerships. PA schools in California. ! Earnings for all primary care physicians in ! In 2016, primary care residency programs in California are slightly higher than the national California filled 1,582 first year (PGY-1) mean, except for Obstetrician/Gynecologists. positions. 24% of these positions were in family medicine, 52% in internal medicine, 6% o Earnings for PAs and NPs are also slightly in obstetrics/gynecology, 17% in pediatrics, higher than the national average. and 1% in combined internal medicine/pediatrics residency programs. © 2017 Healthforce Center at UCSF California’s Primary Care Workforce: Current Supply, Characteristics, and Pipeline of Trainees 6 ! Primary care specialties are among the least ! Several new primary care residency programs popular specialty choices for graduating seniors have opened since 2010, including several from allopathic (MD) medical schools in the U.S. teaching health centers. Some programs have increased the number of residents they ! Only 38% of graduating seniors from train. osteopathic (DO) medical schools in the U.S. plan to practice in a primary care specialty. ! The number of medical residents in primary care ! Family medicine and internal medicine are overstates the number of primary care among the most desirable specialties for physicians in training because substantial California PA students. proportions of residents in general internal medicine and general pediatrics go on to pursue Retention of Trainees subspecialty training or to practice as hospitalists. ! 74% of persons enrolled in MD granting medical schools in California are Californians and 26% Geographic Distribution of Trainees moved to California from another location to attend medical schools. (Similar data are not ! Training programs for MDs, DOs, NPs, and PAs available for other professions.) are clustered in Los Angeles, San Diego, and the Greater Bay Area. ! California exceeds the national average for Demographic Characteristics of Trainees retention of medical school and residency program graduates within the state for clinical ! In 2015, the percentage of female MD graduates practice. (49%) was higher than the percentage of o California retains 63% of medical school females among practicing MDs (36%), indicating graduates and 70% of residency program that percentage of women in the MD workforce graduates compared to national averages of is increasing. 39% and 47%, respectively. (Similar data are o PA and NP graduates are predominately not available for NPs and PAs. female (70% of PAs and 86% of NPs). Data Limitations ! Across all four professions, whites (39%-52%) constituted the largest percentage of graduates ! Existing sources of data on the primary care followed by Asians (25%-36%). clinician workforce in California have some major limitations. ! Latinos remain highly underrepresented among graduates in all four professions—they make up o Analysts must rely on multiple sources of 3% of DOs, 7% of MDs, 9% of NPs, and 14% of data that do not always define terms PAs despite accounting for 38% of the California consistently and are not always available for population. the same time periods. Trainees’ Interest in Primary Care o Prior to 2016, the Medical Board was the only licensing board to collect workforce data from licensees at the time of licensure © 2017 Healthforce Center at UCSF California’s Primary Care Workforce: Current Supply, Demand, and Pipeline of Trainees 7 renewal. This limits the ability to use data in rural areas than in urban areas. In addition, one-third of from California licensing boards to compare California’s primary care MDs are age 55 or older, which findings across primary care professions. will likely exacerbate the shortage of primary care physicians because older physicians provide fewer hours of patient care o The availability of data on practicing than younger physicians and many will retire within the professionals from other sources varies next 10 years. substantially across the primary care The number of residency positions in primary care has also professions. expanded, but not all primary care residents will go on to o New data collection efforts will provide provide primary care or stay in California following additional information on DOs and NPs. graduation. Thus, the numbers of new graduates will not be sufficient to replace all primary care physicians who are " Licensure renewal survey launched by expected to retire within the next decade. Osteopathic Medical Board of California NPs and PAs mitigate some of the primary care physician in 2016 shortage in California, particularly in regions with low ratios of primary care clinicians to population. Their numbers are " Sample survey of NPs to be completed also growing more rapidly than the number of MDs. in 2017 However, the numbers of NPs and PAs remain much " The Board of Registered Nursing and smaller than the number of MDs. In addition, one-third of the Physician Assistant Board are NPs are age 55 or older, which means that many NPs will implementing legislation that requires retire or reduce their work hours within the next 10 years. them to collect demographic and Furthermore, the ratios of NPs and PAs to population in practice data, including: location, California are lower than national ratios, suggesting that specialty, hours worked, type of NPs and PAs are not being utilized as extensively in practice, race/ethnicity, gender, California as in the nation overall. The extent to which the languages spoken, and educational growth in numbers of NPs and PAs in California leads to an background. increase in the number providing primary care will depend on the signals they receive from the labor market. Estimating the primary care clinician supply, distribution, Conclusion and demographic characteristics is severely hindered by a The supply of primary care physicians in California is paucity of standardized data across professions. Future insufficient to meet the population’s needs. Only 36% of workforce planning would improve substantially if MDs provide primary care. A larger percentage of DOs California invested more resources in the collection and provide primary care, but their numbers are so small relative analysis of standardized, comprehensive data on the primary to MDs that they do not fully compensate for the shortage of care workforce. primary care MDs. Primary care physicians are poorly distributed across the state with smaller ratios to population The mission of Healthforce Center is to equip health care organizations with the workforce knowledge and leadership skills to effect positive change. Healthforce Center at UCSF 3333 California Street, Suite 410 San Francisco, CA 94118 © 2017 Healthforce Center at UCSF