alifo rnia health care almanac f ou nd at ion...©2010 california healthcare foundation 5

CAL I FORNIAHEALTHCAREFOUNDATION

californiaHealth Care Almanac

july 2010California Physician Facts and Figures

©2010 California HealtHCare foundation 2

<< r e t u r n to Co n t e n t s

California’s supply of physicians has been growing faster than the overall population in recent years,

rising 7 percent since 1998. demand for physicians is expected to rise, as the senior population grows,

and as more individuals obtain health insurance as a result of health care reform. With large numbers

of physicians nearing retirement, and not all doctors taking patients with private or public insurance,

those seeking care, especially in some regions, could have difficulty finding a provider. this report

draws from numerous sources to describe the market landscape for physician services in California.

Key findings include:

California barely meets the nationally recognized standard for supply of primary care physicians. •

only the orange, sacramento, and Greater Bay area regions meet the recommended supply.

eighty-four percent of PCPs are accepting new patients, and just over half are accepting new •

Medi-Cal patients.

nearly 30 percent of physicians are over 60 years old — a higher percentage than any other state. •

While latinos represent almost 40 percent of the population, only 5 percent of the state’s •

physicians are latinos, which could have implications for language and cultural aspects of care.

California draws a substantial portion of physicians, especially PCPs, from foreign and out-of-state •

medical schools.

While family and general practitioner compensation has been rising, they earned only 88 percent •

of the national average in 2008.

a list of data sources can be found on page 30.

California Physician Facts and Figures

c o n t e n t s

Physician supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

education and training . . . . . . . . . . . . . . . . . . . . . . 16

Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Medical Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Pay for Performance . . . . . . . . . . . . . . . . . . . . . . . . . 26

author, acknowledgments, and data resources . . . . . . . . . . . . . . . . . . . . . . . . 30

appendices

a: definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

B: region Counties . . . . . . . . . . . . . . . . . . . . . . . 32

C: estimated requirements for . . . . . . . . . . . . 33 Physicians per 100,000 Population, by Patient age, united states, 2000

Introduction

©2010 CALIFORNIA HEALTHCARE FOUNDATION 3

<< R E T U R N TO CO N T E N T S

220

230

240

250

260

270

280

20082007200620052004200320022001200019991998

245

262

California Physician Facts and FiguresPhysician Supply

Note: Data includes only MDs with active licenses and includes residents, fellows, and fee-exempt MDs. Excludes MDs with out-of-state zip code and doctors of osteopathic medicine (DOs).

Sources: RAND California, Number of Physicians and Surgeons, ca.rand.org. State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1990 – 1999. Sacramento, CA, May 2009. State of California, Department of Finance, E-3 Race/Ethnic Population Estimates with Age and Sex Detail, 2000 – 2008. Sacramento, CA, June 2010.

*See Appendix C for estimated requirements for physicians by patient age.

The ratio of physicians to

population climbed 7 percent

in the decade from 1998 to

2008. The population as a

whole grew by 16 percent

during this period, while those

over age 65 — the highest

users of physician services —

increased 22 percent.*

Physicians per 100,000 Population, California, 1998–2008

http://ca.rand.org/stats/statlist.html



40 or more51%

30 to 3921%

20 to 2912%

10 to 197%

1 to 96%

3%

None


number of hours worKed

Physician supply

notes: data includes only active California-based Mds who answered relevant questions. excludes residents, fellows, and dos.

source: Medical Board of California, survey of licensees, private tabulation, 2009.

the total number of California

physicians does not accurately

reflect the availability of

physicians to provide care.

only half of the state’s

physicians work full-time in

patient care. other activities

include research, teaching,

and administration.

Physicians, by Average Weekly Patient Care Hours Worked, California, 2009



0 2000 4000 6000 8000 10000

Cardiology

Orthopedic Surgery

Radiology

Emergency Medicine

Obstetrics/Gynecology

Anesthesiology

Psychiatry

Pediatrics

Family/General Practice

Internal Medicine 8,880

7,532

4,734

4,092

3,653

3,157

2,851

2,231

1,874

1,730

California Physician Facts and FiguresPhysician supply

notes: data includes only active California-based Mds who answered relevant questions. excludes residents, fellows, and dos.


active patient care physicians

— those who practice at least

20 hours a week in patient

care — are concentrated in a

handful of specialties. nearly

half work in five specialty

areas, and over two-thirds

work in ten specialties. the

top three specialties are in

primary care.

Top Ten Specialties, by Number of Active Patient Care Physicians, California, 2009



CaliforniaMedical Board Data†

CaliforniaAMA Data

United StatesAMA Data

79 80

140 138

118

63

PCPs Specialists

RECOMMENDEDSPECIALIST SUPPLY(85–105)*

RECOMMENDEDPCP SUPPLY(60–80)*


*the Council on Graduate Medical education (CoGMe), part of the u.s. department of Health and Human services, studies physician workforce trends and needs. the latest CoGMe benchmarks are 60 to 80 PCPs per 100K population, and 85 to 105 specialists per 100K population. CoGMe ratios include dos. the aMa defines active patient care as 20 hours or more a week with a plurality of hours in patient care.

†supply number includes an estimate of dos using aMa data.

note: see Appendix A for PCP specialties.

sources: California HealthCare foundation, Fewer and More Specialized: A New Assessment of Physician Supply in California, june 2009, www.chcf.org. association of american Medical Colleges, 2009 State Physician Workforce Data Book.

California and the nation have

similar per-capita ratios of

primary care physicians and

specialists. However, the state

barely meets the nationally

recognized standard for supply

of primary care physicians,

based on California Medical

Board data.

Active PCPs and Specialists per 100,000 Population, California vs. United States, 2008

http://www.chcf.org/publications/2009/06/fewer-and-more-specialized--a-new-assessment-of-physician-supply-in-california



Greater Bay Area

Sacramento Area

Orange

San Diego Area

Los Angeles

Northern and Sierra

Central Coast

San Joaquin Valley

Inland Empire

PCPs Specialists RECOMMENDED

SPECIALISTSUPPLY

(85–105)*

RECOMMENDEDPCP SUPPLY

(60–80)*40

45

54

57

58

58

64

64

78

70

74

112

113

118

124

121

127

155


*the Council on Graduate Medical education (CoGMe), part of the u.s. department of Health and Human services, studies physician workforce trends and needs. the latest CoGMe benchmarks are 60 to 80 PCPs/100K population, and 85 to 105 specialists/100K population. CoGMe ratios include dos.

notes: data does not include dos. the most recent California data shows 4.3 PCP dos and 3.5 specialist dos per 100,000 population. see Appendix A for PCP specialties and Appendix b for a list of counties within each region.

source: California HealthCare foundation, Fewer and More Specialized: A New Assessment of Physician Supply in California, june 2009, www.chcf.org.

Physician supply varies

by region. some areas

of California do not have

sufficient numbers of

physicians. Both san joaquin

Valley and the inland

empire have fewer PCPs

and specialists than are

recommended by nationally

recognized benchmarks.

Active PCPs and Specialists per 100,000 Population, California Regions, 2008




Non-PCPsPCPsAll Physicians

92%

69%74%

65%

93%

82%

68% 67%65%69%

74%

93%

Private Insurance Medicare Medi-Cal Uninsured

California Physician Facts and FiguresCoverage

source: Physician Participation in Medi-Cal, 2008, California HealthCare foundation, july 2010.

uninsured Californians and

those with public coverage

have less access to physician

care than those with private

insurance. While over

90 percent of California

physicians have patients with

private insurance in their

practices, just 69 percent

have any Medi-Cal patients,

and only 65 percent have

any uninsured patients.

Physicians with Insured Patients in Practice, by Coverage Type, California, 2008



Non-PCPsPCPsAll Physicians

90%

57%

73%

46%

94%

79%

59%

47%42%

54%

64%

84%

Any Medicare Medi-Cal Uninsured

California Physician Facts and FiguresCoverage

source: Physician Participation in Medi-Cal, 2008, California HealthCare foundation, july 2010.

for the many Californians

who will become insured

through the expansion of

public programs due to

national health care reform,

access to physicians may

be limited. only 84 percent

of PCPs are accepting new

patients, and just over half

are accepting new Medi-Cal

patients.

Physicians Accepting New Patients, by Insurance Coverage, California, 2008



0 20 40 60 80 100

U.S.Average

Texas

New York

Illinois

Florida

California

Under Age 40 Age 40 to 60 Age 60 and older

18% 53% 29%

15% 59% 27%

21% 55% 24%

17% 55% 28%

20% 57% 23%

18% 57% 25%


percent of totAl physiciAns

demographics

notes: includes only Mds practicing at least 20 hours a week. segments may not add to 100 percent due to rounding.

source: association of american Medical Colleges, 2009 State Physician Workforce Data Book.

nearly 30 percent of

California’s physicians are

over age 60, the largest

proportion of any state.

this raises concerns about

physician supply as older

physicians begin to retire.

Active Physicians, by Age, California vs. Select States and United States, 2008



0

20

40

60

80

100

1964 and earlier

1965–19741975–19841985–19941995–20042005–2009

5%

11%

24%

57%

6%

12%

23%

55%

5%6%

12%

21%

56%

7%7%

12%

20%

55%

14%

13%

15%

18%

40%

31%

22%

17%

12%

18%

Hours Worked 1 to 9 10 to 19 20 to 29 30 to 39 40 or more

Medical School Graduation Year

—3% —4%

California Physician Facts and Figuresdemographics

notes: data includes only active California-based Mds who answered relevant questions and worked at least one hour in patient care. excludes residents, fellows, and dos. segments may not add to 100 percent due to rounding.


later in their careers,

physicians tend to work

fewer hours a week in

patient care.

Patient Care Hours Worked, by Medical School Graduation Year, California, 2009



Male70%

Female30%

Male50%

Female50%

CALIFORNIA ACTIVE PHYSICIANS

CALIFORNIAMEDICAL SCHOOL GRADUATES

U.S.

Male71%

Female29%

U.S.

Male51%

Female49%

California Physician Facts and Figuresdemographics

sources: association of american Medical Colleges (aaMC), 2009 State Physician Workforce Data Book. aaMC data Warehouse, table 27: total Graduates by u.s. Medical school and sex, 2002–2009.

despite gender parity among

medical school graduates

in California and the nation,

the physician workforce is

still dominated by men, with

women representing less

than one-third of the total. as

more women graduate, that

proportion is likely to grow.

Physicians and Medical School Graduates, by Gender, California vs. United States, 2008



White53%

White41%

Asian21%

Asian12%

Latino5%

African American3%

No Response

12%

Latino37%

Other†

4%

African American6%

Other†

7%

PHYSICIANS* CALIFORNIA POPULATION


*includes only Mds.

†other includes american indian, native american, alaskan native, native Hawaiian, and other.

note: segments may not add to 100 percent due to rounding.

sources: Medical Board of California, 2008 Cultural Background Survey Statistics, www.mbc.ca.gov. u.s. Census Bureau, american Community survey, population estimates, series GCt-t1-r, factfinder.census.gov.

the racial/ethnic composition

of California’s physician

workforce does not reflect

the state’s diversity. While

latinos represent almost

40 percent of the population,

only 5 percent of the state’s

physicians are latinos.

Race/Ethnicity of Physicians and Population, California, 2008

demographics

www.mbc.ca.gov/survey/2008CulturalBackgroundReport.pdf

http://factfinder.census.gov



0 10 20 30 40 50

San Joaquin Valley

Los Angeles

Inland Empire

Central Coast

San Diego Area

Sacramento Area

Greater Bay Area

Northern and Sierra3%

15%

3% 22%

4% 19%

5% 33%

5% 38%

5% 45%

5% 47%

6% 46%

Latino Physicians* Latino Population

CALIFORNIA AVERAGE (5%) CALIFORNIA AVERAGE (37%)


*includes only Mds.

note: see Appendix b for a list of counties within each region.

sources: Medical Board of California, 2008 Cultural Background Survey Statistics, www.mbc.ca.gov. u.s. Census Bureau, annual estimates of the resident Population by sex, race alone or in Combination, and Hispanic origin for Counties in California: april 1, 2000 to july 1, 2008, www.census.gov.

the latino physician under-

representation is most

pronounced in the inland

empire, los angeles, and

san joaquin Valley. in these

regions, the population is

at least 45 percent latino

but only 5 to 6 percent of

physicians are latino.

demographics

Latino Physicians and Population, California Regions, 2008


http://www.census.gov/popest/counties/asrh/files/cc-est2008-5race-06.csv



0 5 10 15 20 25

Los Angeles

Central Coast

Sacramento Area

San Joaquin Valley

Inland Empire

Northern and Sierra

Greater Bay Area

San Diego Area11%

6% 5%

14% 9%

5%

15% 3%

2%

16% 8%

12%

19% 3%

5%

19% 5%

9%

21% 3% 3%

22%10%

9%

Spanish Chinese* Other Asian

CALIFORNIA AVERAGE(8% Chinese, 8% Other Asian)

CALIFORNIA AVERAGE(18%)


for patients, not having

access to a provider who

speaks their language can

have a negative impact on

quality of care. statewide, less

than 20 percent of physicians

speak spanish. in los angeles,

where the population is

47 percent latino, 22 percent

of physicians speak spanish.

Physicians who speak Chinese

or other asian languages

are far less prevalent than

spanish speakers.

*Chinese includes Mandarin, Cantonese, and other Chinese.

notes: includes only Mds. see Appendix b for a list of counties within each region.

sources: Medical Board of California, 2008 Cultural Background Survey Statistics, www.mbc.ca.gov.

demographics

Non-English Languages Spoken by Physicians, California Regions, 2008




0

20

40

60

80

100

Surgical SpecialtiesPCPsAll Physicians

25%

49%

26%

15%

58%

28%

31%

44%

25%

Foreign Other U.S. California


note: see Appendix A for PCP and surgical specialties. segments may not add to 100 percent due to rounding.

sources: California department of Consumer affairs, physician databases, 2004 and 2009, private tabulation. Centers for Medicare and Medicaid, nPi database, May 2009, private tabulation.

California draws a substantial

portion of physicians from

foreign and out-of-state

medical schools. nearly

three-quarters of California’s

physicians attended medical

school out of state, with one

in four studying outside the

united states. almost one in

three California PCPs attended

medical school abroad.

education and training

Physicians, by Medical School Location and Specialty, California, 2009



0

200

400

600

800

1,000

1,200

1,400

1,600

200920082007200620052004200320022001200019991998199719961995

Medical School Graduates

1,01

2

982

20

22

24

26

28

30

32

34

36

38

40

Population (in millions)

31.7

38.5


sources: association of american Medical Colleges, data Warehouse, table 27, 2009. state of California, department of finance (dof), California County Population estimates and Components of Change by year, july 1, 2000 – 2009; sacramento, Ca, december 2009. dof race/ethnic Population with age and sex detail, 1990 –1999, revised May 2009. dof e-3 race/ethnic Population estimates with age and sex detail, 2000 – 2007; sacramento, Ca, May 2009.

the number of graduates

from California’s eight medical

schools has remained relatively

flat over the last 15 years,

in spite of the 20 percent

growth in population. the

university of California,

which operates five of the

programs, has announced

plans to expand enrollment

in existing programs in

addition to opening two

new medical schools.

Medical School Graduates and Population, California, 1995–2009




0

10

20

30

40

50

60

70

80

ResidencyMedical School

62%

39%

69%

47%

California United States


percent of physiciAns prActicing in sAme stAte where educAted

source: association of american Medical Colleges (aaMC), 2009 State Physician Workforce Data Book.

California retains a high

proportion of students who

pursued their education and

residency in the state. in 2008,

California ranked first in the

nation for medical school

student retention, and second

for resident retention.


Retention of Medical Students and Residents, California vs. United States, 2008



0

20

40

60

80

100

PrivatePublic0

50000

100000

150000

200000

PrivatePublic

89%84%

$150,000

$177,500

Medical School Graduateswith Education Debt

Median Total Debt


source: association of american Medical Colleges, Medical Student Education: Costs, Debt, and Loan Repayment Facts, october 2009.

new physicians begin their

careers with significant

educational debt. in 2009, over

80 percent of u.s. medical

students graduated with debt.

the median debt for graduates

of public institutions was

$150,000, while the median

for those from private schools

was $177,500.

Medical School Debt, United States, 2009




0 20 40 60 80 100 120

Family Medicine

Internal Medicine

Pediatrics

Primary Care

Psychiatry

Emergency Medicine

Medical Specialties

Radiology-Diagnostic

Other Specialties

Obstetrics/Gynecology

General Surgery

Anesthesiology

Orthopedic Surgery

Surgical Specialties

116%

87%

85%

80%

100%

83%

65%

71%

56%

42% 45%


percent of students who rAnKed only this speciAlty or rAnKed it first compAred to AvAilAble slots

note: data exclude transitional and preliminary residencies.

source: national resident Matching Program, NRMP Program Results 2005–2009 Specialties Matching Service, www.nrmp.org.

among u.s. medical school

seniors ranking residency

choices, surgical specialties

tend to be more popular

than primary care specialties.

seniors choosing family

medicine as their first or only

choice fill only 42 percent of

the available slots.

Medical Student Specialty Choices Compared to Available Slots, United States, 2009


http://www.nrmp.org/data/programresultssms2005-2009.pdf



2004 2005 2006 2007 2008CHanGe

2004 – 2008

Primary Care

family and General Practitioners $119,010 $133,420 $136,290 $139,130 $142,620 19.8%

internists, General $168,820 $149,600 $162,340 $160,460 $172,560 2.2%

Pediatricians, General $139,020 $145,210 $148,250 $155,230 $156,830 12.8%

Specialists

anesthesiologists $196,250 $186,390 $193,780 $201,170 $209,900 7.0%

obstetricians/Gynecologists $181,070 $179,270 $178,160 $173,870 $181,520 0.2%

Psychiatrists $180,550 $171,590 $176,700 $151,680 $155,190 – 14.0%

surgeons $168,220 $158,980 $165,570 $171,200 $202,940 20.6%

Consumer Price index (CPi) ($100,000 base)

$100,000 $103,057 $103,419 $103,175 $103,494 3.5%


notes: includes only practicing physicians. does not include self-employed or government-employed physicians. in 2008, salary data for all physicians was based on 53,450 physicians practicing in California. it does not include ancillary income from sources such as directorships, call coverage, etc.

source: Bureau of labor statistics (Bls), occupational employment statistics surveys, May 2000 – 2008; Bls all urban Consumers, all items, Western u.s. CPi – annual (series Cuus0400sa0), www.bls.gov.

family and general

practitioners’ salaries

lagged other specialties,

despite a large increase

between 2004 and 2008.

during the same time,

psychiatrists saw a decline

in income while salaries for

surgeons, pediatricians, and

anesthesiologists rose more

than the CPi.

Average Annual Employed Physician Earnings, Select Specialties, California, 2004–2008

Compensation

www.bls.gov/oes/oes_dl.htm



0 20 40 60 80 100 120

Family and General Practitioners

Obstetricians/Gynecologists

Surgeons

Internists, General

Psychiatrists

Pediatricians, General

Anesthesiologists 106%

102%

101%

98%

98%

94%

88%

CPICALIFORNIA AS PERCENT OF U.S.

(106.5%)


notes: includes only practicing physicians. does not include self-employed or government-employed physicians. does not include ancillary income from sources such as directorships, call coverage, etc. Comparison is in nominal dollars; all bars would be 6.5 percent lower if adjusted for the higher cost of living in California.

sources: Bureau of labor statistics (Bls), occupational employment statistics surveys, May 2000 – 2008, www.bls.gov. Bls, Consumer Price index, 2009 – 2010, www.dir.ca.gov.

Compensation

in 2008, most of California’s

specialists averaged earnings

similar to their national

peers, without adjusting

for California’s higher cost

of living. the largest outlier

was family and general

practitioners, who earned

less than 90 percent of the

national average.

AverAge AnnuAl employed physiciAn eArnings As A percent of nAtionAl AverAge

Physician Earnings, by Select Specialties, California vs. United States, 2008

www.bls.gov/oes/oes_dl.htm

www.dir.ca.gov/dlsr/CPI/PresentCCPI.PDF



0

20

40

60

80

100

Income fromMedical Practice

Time to SpendPer Patient

Overall Experiencewith Practicing Medicine

8%

32%

41%

18%

11%

32%

41%

15%

18%

52%

28%

Very Dissatis�ed Somewhat Dissatis�ed Somewhat Satis�ed Very Satis�ed

— 2%


note: segments may not add to 100 percent due to rounding.

source: Health Perspectives in California, 2007 Survey of Primary Care Physicians. Harris interactive. june 2007.

a survey of California primary

care physicians found that four

in five were either somewhat

or very satisfied with their

overall experience practicing

medicine. However, two in

five were somewhat or very

dissatisfied with their medical

practice incomes.

Primary Care Physician Satisfaction, California, 2007

satisfaction



GroupPractice18%

GroupPractice57%

IPA52%

IPA28%

Foundation7%

CommunityClinic15%

County Group6% UC Group

1%

County Group3%Community

Clinic4%

Foundation7%

UC Group2%

TYPE OF GROUPn=282

ENROLLMENTn=15.8 million


notes: includes medical groups with at least six PCPs and accepting contracts directly from HMos. Physicians frequently participate in more than one iPa. see Appendix A for definitions of medical groups. segments may not add to 100 percent due to rounding.

source: Cattaneo & stroud, Medical Group survey; september 2009, www.cattaneostroud.com.

Physicians are often part of

medical groups. over 280

medical groups provide care

to nearly 16 million health

maintenance organization

(HMo) enrollees in California.

While half of these groups

are independent practice

associations (iPas), group

practices have the largest

total enrollment.

Medical Groups, by Type and Enrollment, California, 2009

Medical Groups

www.cattaneostroud.com/medgroup_reports.htm



All Other Groups35%

Top 5 Largest48%

6–15th Largest

11%

6%16–25th Largest


Percent of total HMo enrollMent

notes: includes medical groups with at least six PCPs and accepting contracts directly from HMos.


California’s managed

care enrollees are highly

concentrated in a handful of

medical groups, with the top

five groups enrolling almost

half of all members.

Medical Groups, by Member Enrollment, California, 2009

Medical Groups




0

50

100

150

200

250

200820072006200520042003

Medical Groups

215 230 228 235 233 229

0

10

20

30

40

50

Physician Participation (in thousands)

40 40

45

40

3535


notes: the integrated Healthcare association, which provides oversight to the Pay for Performance (P4P) program, is a group of health plans, physician groups, and systems that promotes quality, affordability, and accountability of health care providers. its goal is to create incentives that will drive improvements in clinical quality, efficiency, and the patient experience through a common set of measures, a public report card, and health plan incentive payments.

source: integrated Healthcare association, www.iha.org, accessed March 24, 2010.

Many California medical

groups and physicians

participate in Pay for

Performance (P4P), a program

that provides financial

incentives for meeting quality-

of-care and efficiency targets.

the number of physicians

participating in P4P peaked

at 45,000 in 2005 and has

since dropped to 35,000.

Medical Groups and Physician Participation in Pay for Performance, California, 2003–2008

Pay for Performance

http://www.iha.org/program_results.html



0 10 20 30 40 50 60 70 80

Sacramento Area

Greater Bay Area

Northern and Sierra

San Diego Area

Orange

San Joaquin Valley

Central Coast

Los Angeles

Inland Empire 62.1

65.0

67.5

68.5

70.3

70.5

73.5

76.5

76.7

(22 groups)

(65 groups)

(9 groups)

(14 groups)

(18 groups)

(17 groups)

(3 groups)

(30 groups)

(10 groups)

CALIFORNIA AVERAGE(68.6%)


notes: the clinical composite scores in the chart are based on 16 eligible clinical measures in measurement year 2008 (“My 2008”). the measures are equally weighted to form a clinical composite. for any eligible physician organization that had missing data, an adjusted half-scale rule was applied. see Appendix b for a list of counties within each region.

source: integrated Healthcare association Pay for Performance data, Measurement year 2008.

Physician group performance

on Pay for Performance (P4P)

clinical quality measures varies

widely by region. Greater

Bay area physician groups

participating in P4P averaged

76.5 on a composite quality

score, while los angeles

groups performed more than

ten points lower.

P4P Physician Group Clinical Quality Scores, California Regions, 2008

Pay for Performance



0 20 40 60 80 100

California Average

Inland Empire

Los Angeles

Orange

San Diego Area

San Joaquin Valley

Sacramento Area

Central Coast

Greater Bay Area

Northern and Sierra 14% 86%

2 7% 42% 50%

6% 6% 50% 38%

13% 50% 38%

7% 14% 46% 32%

9% 26% 48% 17%

10% 31% 41% 17%

14% 32% 40% 15%

22% 33% 39% 6%

9% 20% 40% 31%

Poor Fair Good Excellent


notes: each medical group’s patient records are compared to a set of national standards for quality of care on an annual basis. sixteen quality measures such as immunizations for children, cholesterol tests for people with heart disease and diabetes, and pap smears for women are evaluated. each group is awarded an aggregate quality score of excellent, Good, fair, or Poor. segments may not add to 100 percent due to rounding. see Appendix b for a list of counties within each region.

source: office of the Patient advocate, Medical Group ratings, May 2009 ratings based on 2008 data, www.opa.ca.gov.

an annual public report card

issued by California’s office of

the Patient advocate shows

how well groups participating

in P4P have performed on

16 quality measures. in 2009,

Greater Bay area medical

groups scored well on these

measures — 92 percent of

groups received a “Good”

or “excellent” rating. only

45 percent did so in the

inland empire.

Pay for Performance

P4P Physician Groups Meeting National Standards of Care, California Regions, 2008

http://www.opa.ca.gov/report_card/medicalgroupcounty.aspx



0 10 20 30 40 50 60 70 80

Actionable Report/Data Warehouse

HEDIS Results

Computerized Registries

Electronic Lab Results

Accessing Clinical Notes of Other Practitioners

Physician Preventive/Chronic Care Reminders

Electronic Messaging

Electronic Drug Checks

Accessing Clinical Findings Such as Blood Pressure

Ordering Lab Tests

Electronic Prescribing 31%

38%

39%

39%

49%

51%

56%

56%

62%

63%

67%

Point of Care Population Management


source: integrated Healthcare association, Pay for Performance (P4P) 2008 Results Report, august 2009.

Physician groups participating

in Pay for Performance (P4P)

are measured and rewarded

for their use of health

information technology (it).

almost 62 percent of these

groups use it to create

patient registries. use of it at

the point of care is less well-

established within P4P groups,

although over half use some

of these technologies such as

accessing electronic lab results

and clinical notes of other

practitioners.

P4P Physician Groups Using Health Information Technology, California, 2008

Pay for Performance

©2010 CALIFORNIA HEALTHCARE FOUNDATION 30

<< R E T U R N TO CO N T E N T S

F O R M O R E I N F O R M AT I O N

California HealthCare Foundation

1438 Webster Street, Suite 400

Oakland, CA 94612

510.238.1040

www.chcf.org

CAL I FORNIAHEALTHCAREFOUNDATION


AuthorCraig Paxton, Ph.D., Cattaneo & Stroud, Inc.

AcknowledgmentsThe author would like to thank Emily Willig for

diligent data compilation, and partners Penny Stroud

and Grant Cattaneo for critical expertise.

Data ResourcesAssociation of American Medical Colleges

Semi-annual reports on state physician workforce, as well as data on medical

school students and graduates, and medical student tuition and debt.

www.aamc.org

California Department of Consumer Affairs Physician licensing data on doctors of medicine and osteopathic medicine.

www.dca.ca.gov

California HealthCare Foundation “Fewer and More Specialized: A New Assessment of Physician Supply in

California.” The first comprehensive study of the Medical Board of California

survey data on practicing physicians in the state, with an Excel spreadsheet

showing the number of physicians, by specialty, for each California county.

www.chcf.org

Cattaneo & Stroud Medical group survey reports.

www.cattaneostroud.com

Integrated Healthcare Association Reports on physician participation and performance in California’s Pay for

Performance program.

www.iha.org

Medical Board of California Annual reports on physician cultural background and foreign language

proficiency, by zip code and county; physician level survey data.

www.medbd.ca.gov

Office of the Patient Advocate Reports on medical group ratings.

www.opa.ca.gov

http://www.chcf.org

http://www.aamc.org/start.htm

http://www.dca.ca.gov


http://www.cattaneostroud.com/medgroup_reports.htm

http://www.iha.org/p4p_california.html

http://www.medbd.ca.gov/survey/statistics.html

http://www.opa.ca.gov



medical groupsMedical groups are organized and managed in several

different ways:

Community Clinic.• a clinic that operates under

California Health and safety Code 1204(a), which

requires that it provide care to low-income and

underserved populations, and charge fees based on

patients’ ability to pay. a community clinic is operated

by a tax-exempt nonprofit corporation, supported by

either public or private donations and contributions.

County Group.• a county-formed group of

physicians that typically provides services through

the county health department.

Foundation.• a type of group practice under

California Health and safety Code 1206(l), which

stipulates that a medical foundation must operate

a not-for-profit, tax-exempt clinic, conducting

research as well as providing patient care and

health education. the foundation must have at least

40 physicians, at least ten of whom have to be board

certified, and at least two-thirds of all physicians

must practice on a full-time basis at the clinic. the

physicians are independent contractors to the

foundation, but the foundation owns the facilities,

equipment and supplies, and employs all non-

physician personnel.

Group Practice.• a corporation, foundation,

partnership, or other type of organization formed

for the purpose of providing patient care. Group

practices are more regulated than iPas. to be

recognized by CMs as a group practice, the

organization must direct the majority of its physicians’

bills through the organization, pay for their own

overhead, and follow other regulations specified

under California Health and safety Code 1206(l).

Independent Practice Association (IPA).• an

association that contracts with independent

physician practices so that they may work together as

one when contracting with HMos and other payers.

University of California Medical Center.• a medical

group operated by the university of California as part

of one of its medical schools.

specialtiesMedical Specialties include: aerospace Medicine,

allergy and immunology, Cardiology, Complementary

and alternative Medicine, Critical Care, dermatology,

emergency Medicine, endocrinology, Gastroenterology,

Hematology, infectious disease, Medical Genetics,

neonatal-Perinatal Medicine, nephrology, neurology,

occupational Medicine, oncology, other Medical Practice,

Pain Medicine, Physical Medicine and rehabilitation,

Psychiatry, Public Health and General Preventive,

Pulmonology, rheumatology, and sleep Medicine.

PCP Specialties include: family/General Practice,

internal Medicine, Pediatrics, adolescent Medicine, and

Geriatric Medicine.

Surgical Specialties include: anesthesiology, Colon

and rectal surgery, Cosmetic surgery, facial, Plastic and

reconstructive surgery, General surgery, neurological

surgery, obstetrics and Gynecology, ophthalmology,

orthopedic surgery, otolaryngology, Plastic surgery, spine

surgery, surgical oncology, thoracic surgery, urology, and

Vascular surgery.

Other Specialties include: nuclear Medicine, Pathology,

radiation oncology, and radiology.

California Physician Facts and Figuresappendix a


Definitions




central coast Monterey, san Benito, san luis obispo, santa Barbara, santa Cruz, Ventura

greater bay Area alameda, Contra Costa, Marin, napa, san francisco, san Mateo, santa Clara, solano, sonoma

inland empire riverside, san Bernardino

los Angeles los angeles

northern and sierra alpine, amador, Butte, Calaveras, Colusa, del norte, Glenn, Humboldt, inyo, lake, lassen,

Mariposa, Mendocino, Modoc, Mono, nevada, Plumas, shasta, sierra, siskiyou, sutter,

tehama, trinity, tuolumne, yuba

orange orange

sacramento Area el dorado, Placer, sacramento, yolo

san diego Areaimperial, san diego

san Joaquin valley fresno, Kern, Kings, Madera, Merced, san joaquin, stanislaus, tulare


Region Counties appendix B



Age group primAry cAre1medicAl

speciAlties2surgicAl

speciAlties3other

speciAlties4 totAl

0 to 17 95 10 16 29 149

18 to 24 43 15 54 48 159

25 to 44 59 23 52 62 196

45 to 64 89 41 59 81 270

65 to 74 175 97 125 145 543

75 and older 270 130 161 220 781

notes: authors calculated ratios based on physician use patterns and patterns of care in 2000. 1. includes general and family practice, general internal medicine, and pediatrics. 2. includes cardiology and other internal medicine subspecialties. 3. includes general surgery, obstetrics/gynecology, ophthalmology, orthopedic surgery, otolaryngology, urology, and other surgical specialties. 4. includes anesthesiology, emergency medicine, pathology, psychiatry, radiology, and other specialties.

source: u.s. department of Health and Human services, Health resources and services administration, Bureau of Health Professions, The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand, december 2008.

California Physician Facts and Figuresappendix C

Estimated Requirements for Physicians per 100,000 Population, by Patient Age, United States, 2000

alifo rnia health care almanac f ou nd at ion...©2010 california healthcare foundation 5

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