Last updateMon, 20 Apr 2020 1pm

Primary care doctors are a hot commodity across California.

Students are being lured by full-ride scholarships to medical schools. New grads are specifically recruited for training residencies. And full-fledged doctors are being offered loan-repayment programs to serve low-income residents or work in underserved areas.

These efforts are intended to ease or stave off the physician shortage expected to peak within the next decade in California. By 2030, the state will be short some 4,000 physicians, according to a study from the HealthForce Center at UC San Francisco.

The shortage is already acute in rural and inner-city areas—especially in the Inland Empire of Southern California, where the number of physicians needs to double just to reach the recommended amount to serve the fast-growing population.

“The Inland Empire region has one of the lowest ratios of physicians, including primary-care physicians, and that creates a number of challenges,” said Dr. Geoffrey Leung, ambulatory medical director for the Riverside University Health System. “When we have delays in care, that can result in sort of chronic illnesses or acute illnesses that become worse.”

With high student loans, medical-school grads have been turning to better-paying specialties instead of primary care, such as family practice, pediatrics or obstetrics, leaving some areas in dire need.

“In California in particular, what’s unique is that the total number of physicians isn’t as big of a problem as where they are located,” said Mark Henderson, professor of internal medicine and associate dean of admissions at the UC Davis School of Medicine. “It’s really a maldistribution problem.”

Health insurers, medical professionals and community leaders are working on solutions. This summer, the state offered 250-plus doctors loan-repayment plans in exchange for ensuring 30 percent of their caseloads were Medi-Cal patients.

Meanwhile, insurer L.A. Care is spending millions on recruiting new doctors. In South Los Angeles, the Martin Luther King Jr. Community Hospital is working to create a new residency program. In the Inland Empire, leaders are working to create a “middle school to medical school” pipeline.

Because doctors tend to practice near where they trained, where they are from or where they have a family connection, resources are being poured into the expansion or creation of training programs that are situated where the need is.

Most Impacted Region: The Inland Empire

Inland Empire officials have been working on this for quite some time. A statewide report from the California Future Health Workforce Commission released this year found the number of physicians is 35 per 100,000 people, compared to the recommended 70 doctors, making it the most impacted region in the state.

Because of that need, the state approved a new University of California medical school that opened in 2013 at UC Riverside specifically to train doctors to serve the local area. It offers scholarships to students who promise to return after residency to practice in the area, and reaches out to kids interested in health careers.

The county and medical school have partnered to expand long-standing residency programs by inviting more students to train in the area. And both institutions recruit with an eye toward geographic nativity, meaning if an applicant is from or has a connection to the area, they get priority.

For cancer survivor Cesilia Jimenez, these efforts by the county are paying off. Jimenez recently received the results of her latest scans at the Moreno Valley Community Health Center from Dr. Moazzum Bajwa.

She had been putting it off.

“I’ve been so nervous to hear those results. I knew I wanted to hear them from you,” she told Bajwa after he assured her that everything on the scans looked good.

It was Bajwa, who was a resident at the time, who diagnosed a cancerous tumor in her neck and got her treatment for it after she had sought answers for years as to why she was losing her ability to walk.

He is now an attending physician and teaching residents through the Riverside University Health System and the UCR medical school. Bajwa is considered a success story in Riverside County’s efforts to grow, recruit and retain primary care doctors in the region.

So far, the county is seeing success, Leung said. About four out of 10 residents stay in the Inland Empire after their training, and eight to nine stay in Southern California. While those numbers are not that different from other programs across the state, opening the medical school and expanding training slots have kept doctors in the area.

Dr. Takesha Cooper is on the admissions committee at the medical school, where priority is given to applicants who have a permanent or active mailing address in the area, or went to college or attended high school in the Inland Empire.

“We do a holistic review and don’t just look at test scores,” she said. “We call it ‘mission fits.’”

Cooper defines it as applicants with connections to the area and who believe in the school’s mission to help the medically underserved region and train a diverse workforce of physicians. “We have to focus and attract and try to keep people who are growing up in this area, who have ties and are more likely to stay,” she said.

So far, the medical school is seeing early success. Of its 128 graduates, about 31 percent are training as residents in the Inland Empire.

“I Needed to Serve This Population”

Cooper is the kind of local student the school hopes to capture.

She grew up in Moreno Valley long before the medical school opened. She went away for college, completed medical school at the University of Southern California, and moved to the Bay Area for her residency and a fellowship in child and adolescent psychiatry.

And, as statistics bear out, she set up her practice in Palo Alto—near Stanford, where she finished her training.

“I did that for five years, but I started to feel like I’m not really needed here,” she said. “My heart told me I needed to serve this population.”

So she came back to Riverside to practice, and then she joined the faculty at UCR and has since helped start a residency in general adult psychiatry and a fellowship in child psychiatry, as ways to train and keep much-needed mental-health professionals in the area.

“If our residents had to go to UCLA or UC San Diego or Irvine, chances are they would have stayed in that area and practiced,” she said. “It’s what I did.”

It’s the same strategy the county uses in recruiting medical school graduates like Bajwa to its residency programs, said Dr. Adolfo Aguilera, associate director of the University Health System residency program, who also stayed on after he trained in Riverside more than two decades ago.

“When somebody has a connection to the area, you know, they are invested in what they’re going to be doing,” he said. “If they’re here to stay, they’re going to want to make sure that they are providing the best care that they can, that they are essentially trying to build the program so that we’re able to outreach to our community and serve their needs”

Bajwa is from the East Coast, but the program’s goals matched his when he interviewed, and Riverside was his first choice. He also had another reason for coming and staying: His wife is from Riverside, and she’s also a physician.

“The connection with my wife is what brought me out here first,” he said. “But it was the community and identity of building something bigger than myself that I fell in love with.”

That’s what Leung, Aguilera and others in Riverside hope will happen with many of the students and residents they recruit. And they are not alone.

Recruiting Physicians Where They Are Needed

This kind of thinking is happening across the state in areas lacking physicians.

In Northern California, UC Davis has partnered with the Oregon Health and Science University in Portland and created a program called COMPADRE, or California Oregon Medical Partnership to Address Disparities in Rural Education. It focuses on the area between Davis and Portland to recruit kids to medical school and to provide a program that allows them to train where they are from.

“We’ll modify their curriculum to allow them to remain in their home community for a large part of their training to keep them connected to a community health center in the region,” Henderson said. “If we get physicians who actually grew up or have a connection to these communities, they will be less burned out and will have meaningful relationships to the community and the hospital.”

In urban South Los Angeles, the MLK Jr. Community Hospital set up its own medical group in 2016 that recruits and hires physicians to practice in the neighborhood. It is slated to start a residency training program in 2022, said Elaine Batchlor, CEO of the hospital.

“The strategy is to recruit doctors who have an interest in working in underserved communities, to offer them a state-of-the-art practice environment with high quality colleagues,” she said. “We offer market compensation and the possibility of having loans forgiven, because they are working in a medically underserved area.”

Bringing residency slots to communities is a strategy that costs money. These slots are usually paid for by the Medicare program, but the federal government has not created new residency positions in years. So the program at MLK and other new training sites are being funded by the host institutions or insurers like L.A. Care Health Plan.

L.A. Care serves 2 million Medi-Cal patients in Southern California. Last year, the insurer committed 5 percent of its reserves—about $31 million a year for five years—to a program called Elevating the Safety Net, said John Baackes, CEO of the organization. It includes scholarships for medical school students, funding for residency slots, grants to clinics and private practices to recruit primary care doctors into Los Angeles County, and loan repayment up to $180,000 for those newly recruited physicians who stay three years.

“We’re hoping that when their three years is up, they will have fallen in love with L.A. and their practice, and they’ll stay on with us,” Baackes said. “We’re aimed at the safety-net populations, those people who are on Medi-Cal or uninsured, and we think this is the right thing to do is invest in the future of this population.”

In Riverside, the residency program that produced Dr. Bajwa is also partly supported by the county. Riverside County funds 52 positions beyond what the federal government provides.

“We are over our cap, which means every resident that we add on top of that limit is entirely funded through the county,” said Leung, of Riverside University Health System. “Any improvement that we make in the Inland Empire area—whether it is in workforce, education or in terms of policy or the way we think about developing neighborhoods—all of those things help make the Inland Empire the sort of area that people want to move to and that help us with recruiting doctors, resident physicians and medical school students.”

For patients, having access to a doctor over the long term that they know and trust pays off.

Before Dr. Bajwa, Cesilia Jimenez never knew who she was going to see at the clinic.

“It feels good to just come, and he knows what we are going to talk about, and not me explaining to the doctor what I’ve been through,” she said.

When she left their appointment, Bajwa gave her a hug before she walked out on her own.

“Many programs talk about serving the underserved, but here, the focus that the faculty have on actually taking care of the community and doing outreach in the community is just unparalleled I think,” Bajwa said. “That was something I wanted to be a part of.” is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Features

In one of his first official actions, Gov. Gavin Newsom has directed state agencies, including the one that oversees Medi-Cal, to negotiate as a block to demand prescription drug-makers lower their prices.

The move will make California the nation’s largest negotiator with pharmaceutical companies, and could become a model for other states—if it works.

“Right now, with all the gridlock in Congress, we are seeing quite a bit of state action on prescription-drug pricing—and we hope that advances as much as it can until we can see some change in Congress,” said Peter Maybarduk, who specializes in medicine access at Public Citizen, a consumer advocacy group based in Washington, D.C.

“California government has power,” he continued. “It is a large enough economy and large enough state to influence pharma behavior and dictate terms.”

It’s such an attractive idea that it seems to have united the progressive Newsom with his political nemesis, President Donald Trump. Both have espoused the wisdom of the government consolidating its massive purchasing power so it can bargain hard with drug companies and cut the best deal for taxpayers.

Trump campaigned on the notion of harnessing the federal government’s bargaining power to reduce drug prices for programs like Medicare, but the idea went nowhere, because it’s prohibited by federal law: Congress specifically barred the federal government from negotiating Medicare drug prices—a restriction defenders describe as free-market protection and critics deride as a giant pacifier to Big Pharma.

Still it remains a simple and appealing idea in a nation confronted by rapidly rising prescription drug costs. A recent Harvard/Politico poll found the No. 1 priority voters have for the new Congress is reducing the cost of prescription drugs.

There’s a reason it’s top of mind. A study released this month in the Journal of Health Affairs found that the cost of brand-name drugs rose each year between 2008 and 2016—by more than 9 percent per year for oral medicine, and more than 15 percent for injectable medicine. Specialty drug prices soared even higher each year.

In his executive order, Newsom said California has seen prescription drug prices rise 20 percent annually since 2000—and that the 25 most expensive drugs account for half of the state’s spending on pharmacy costs. So far, Newsom’s office has not released any estimates of how much it expects the new bargaining plan to save.

“We will use both our market power and our moral power to demand fairer prices for prescription drugs,” Newsom said during his inauguration speech Monday.

That same day, he told the state’s Department of Health Care Services to begin negotiating the purchasing of prescription drugs for all 13 million recipients of Medi-Cal, the state’s health-care system for low-income patients. Currently, the state only represents 2 million of them, while the rest are on managed health plans that negotiate their own drug rates.

“The governor is the only one that can do this; he is the only one that can force everybody to the table,” said Democratic Assemblyman Jim Wood of Healdsburg, who heads the state Assembly’s health committee.

He said the consolidated bargaining power is vital to address skyrocketing drug prices. With nearly one in three Californians on Medi-Cal, and its budget of $250 billion, even small savings could be significant.

“The savings we’ll be able to enjoy from less spending on prescription drugs,” Wood said, “will help offset some of the additional costs that we’re going to be incurring to expand coverage for other people in California.”

Massachusetts was the first state to enact a “bulk Rx buying plan” in 1999. States eventually started joining forces, and now there are five bulk-buying programs that include multiple states, with some reporting significant savings. Three of those are focused on buying drugs for Medicaid recipients, according to the National Conference of State Legislatures.

The oldest one, focused on Medicaid pooling, was created in 2003 with four states and has now grown to 10, including Michigan, Minnesota, Montana, New York and North Carolina. It represents 3.8 million Medicaid recipients—still less than a quarter of the Medi-Cal recipients California will be bargaining on behalf of.

In its last session, the California Assembly approved a bill that would have created a prescription drug bulk-purchasing program for the state, but it was then held by its sponsor, San Francisco Democratic Assemblyman David Chiu. His office cited a lack of support from then-Gov. Jerry Brown. And nearly two decades ago—in another effort to decrease drug expenses—the state authorized the Department of General Services to buy prescription drugs for state or local agencies through a bulk purchasing program, but the program hasn’t been used much.

The governor’s plan also calls for eventually giving private employers the option to join the consolidated purchasing block, although how that would work is still vague.

As for the expected drug-industry opposition, the Pharmaceutical Research and Manufacturers of America said it’s reviewing the proposal.

“We welcome the opportunity to work with the governor and his administration on comprehensive solutions to the problems patients are facing accessing and affording their medicines,” said spokeswoman Priscilla VanderVeer.

Gerald Kominski, senior fellow at the UCLA Center for Health Policy, lauded the idea of using market power to obtain the lowest prices possible, but predicted that drug-makers would unleash a campaign against it inside and outside of California.

“They will start running ads that are going to scare people—that if you are on Medi-Cal, you are no longer going to get this drug or this drug,” he said. “There will be dark music and maybe a doctor in the scene shaking their head 'no' saying you are no longer eligible for this or for that.”

For the health plans that currently serve the majority of Medi-Cal patients, efforts to get better prices are welcome, said John Baackes, CEO of L.A. Care Health Plan. With 2.5 million Medi-Cal patients, it is the largest Medi-Cal managed plan in the state.

“We are supportive of investigating the idea, because logically it says if the state is negotiating for 13.5 million people, they can do a lot, maybe more than what we can do for 2 million people,” he said. “It’s worth it to see if it will produce better pricing.”

But the details are going to matter, Baackes said. There has been no information yet on how it will be administered or how the state would handle customer service.

Even California, with super-sized buying power, can only bargain so far. Larry Levitt, senior vice president of the Kaiser Family Foundation, called Newsom’s approach “promising.” But he noted that the state can’t walk away from a negotiation, because it has an obligation to make sure that Medi-Cal recipients can access the drugs they need.

“Leveraging the purchasing power of the state is certainly a smart move,” said Sacramento Democratic Senator Richard Pan, chair of the Senate Health Committee. But he added a caveat: “We want to make sure it’s done in a way that ensures that people have access to the medication they need.” is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Politics