No evidence that large numbers of physicians are leaving California, say UCSF researchers

By Maureen McInaney

Anecdotes abound about the tumultuous state of physician affairs in California.
However, there is no objective evidence that large numbers of doctors are
leaving California, according to a report released by the UCSF Center for
Health Professions.

In fact, the ratio of physicians to population has increased from 177 doctors
for every 100,000 people in 1994 to 190 per 100,000 in 2000. This is above the
requirement set forth by the Council on Graduate Medical Education (COGME),
according to the report titled The Practice of Medicine in California: A
Profile of the Physician Workforce, the third in a series released by the UCSF
Center for Health Professions’ California Workforce Initiative.

## The report’s findings refute the following:

* California now has too many primary care physicians and not enough
specialists.

* Doctors are leaving major urban centers in California.

* Doctors are shunning managed care and finding plenty of patients without
needing to contract with managed care plans.

* Physicians’ earnings are plummeting.

The study finds that in 2000, slightly more than one third of California’s
active, patient-care physicians practiced in the generalist fields of medicine
(family practice, general practice, general internal medicine, and general
pediatrics). “Although California still has many more specialists than
generalists, the growth of specialists was slightly slower in recent years
relative to the growth of generalists,” said Kevin Grumbach, MD, UCSF associate
professor of family and community medicine and co-principal investigator on the
study. “The data indicate that public policy and the managed care environment
in California may have had a modest effect on slowing the rate of growth of
specialists relative to the rate of growth for generalists. However, the
magnitude of this effect falls well short of the suggested mass exodus of
specialists in California.”

The UCSF investigators also noted that despite the highly competitive
environment in densely populated areas such as San Francisco and Los Angeles,
physicians have not migrated to less competitive, lower supply regions in
California in sufficient numbers to change significantly the distribution that
already exists in the state. Much of the Central Valley and eastern portions of
the state still have ratios of physicians to population below recommended
minimum requirements, despite the overall abundance of physicians in
California.

Contrary to anecdotal reports, most physicians are not shunning managed care,
according to the investigators. In 1998, about half of generalists and
one-third of specialists in urban California had the majority of their patients
enrolled in HMOs (including private, Medicare, and Medi-Cal HMOs). And in 1998,
only sixteen percent of generalists and 20 percent of specialists had no HMO
patients in their practice.

However, physicians clearly are experiencing many stresses in the current
managed care environment, including perceived pressures to see more patients
per day and to limit medical tests and specialist referrals, said Grumbach.

“The tenor of media and trade publication articles suggest a high level of
anxiety among California doctors in a managed care environment where some
perceive physicians to be working more and making less,” said O’Neil. “Although
managed care may be dampening the rate of increase of physician incomes,
especially for specialists, California physicians have median incomes ranging
from $120,000 to $250,000. These are comparable to those reported for
physicians nationwide and well above $33,000, the mean income for California.”

## The report also includes a synopsis of demographic and medical training data:

* Most California physicians are male and white—with the largest group
comprised of physicians between ages 45 and 54.

* The physician workforce is slowly but steadily approaching parity between the
numbers of female and male physicians. California is on par with national
estimates that women will constitute more than a third of active physicians in
the U.S. in 2020.

* Women physicians are more likely than men to choose primary care specialties
and obstetrics and gynecology.

* The state’s physician workforce is losing ground in terms of its racial and
ethnic diversity. African Americans and Hispanic/Latinos each comprised less
than 5 percent of the state’s physicians, although they made up 7 and 31
percent of the state’s population respectively. Medical education pipelines do
not show significant advances in recent years in racial and ethnic diversity.

* Only about a quarter of physicians practicing in California in 2000 attended
medical school in the state. About 50 percent of the state’s physicians
attended school in another U.S. state and the remaining 25 percent attended
school outside the U.S.

* A slight majority (55 percent) of the physicians practicing in California in
2000 did their residency training in the state. The remaining 45 percent
completed their residencies outside California.

The report was made possible through the support of the California HealthCare
Foundation which, in partnership with The California Endowment, funds the
California Workforce Initiative.

The California HealthCare Foundation is an Oakland-based, independent
non-profit philanthropic organization whose mission is to expand access for
underserved individuals and communities, and to promote fundamental
improvements in health status of the people of California.

The California Endowment is a private foundation with staff throughout the
state whose grants are made to organizations and institutions that directly
benefit the well being of Californians.

Additional support for research activities contributing to this report came
from the Bureau of Health Professions, Health Resource and Services
Administration; the Agency for Health Care Research and Quality; and the
California Program on Access to Care, California Policy and Research Center.

The California Workforce Initiative will be conducting a survey of physicians
in the state during 2001. For more information, visit www.futurehealth.ucsf.edu