Workers expect their defined contribution plans to play a greater role in their retirement income than annuities.
Aug. 15--Kristina Rodriguez grew up in Healdsburg caring for her ailing grandfather, an immigrant from central Mexico who raised his family while working on railroads in Northern California. The experience tending to a loved one through a progression of problems -- from intense stomach pains to diabetes and liver failure -- gave Rodriguez a glimpse into the complicated world of health care.
What really struck her, however, was something simple: Her grandfather's deep relationship with his primary care doctor.
"He struggled so much in his life, so seeing the doctors really care about him and his health meant so much to me," she said. "They developed such a strong relationship that his doctor even came to his funeral when he passed away."
Now Rodriguez, 23, wants to join the ranks of local family doctors. This summer, she was one of six people selected for a fast-track joint medical program offered by the UC Davis School of Medicine in partnership with Kaiser Permanente.
The three-year program, shortened from the standard four-year medical education, is the first of its kind in California. It aims to fill what health care officials and medical experts call a perilous shortage of primary care physicians nationwide.
The dwindling supply of family practitioners, who handle patient needs including childbirth, preventive care, obstetrics and gynecology, is a not a new problem; but it is growing more pronounced as graduating physicians -- faced with hefty six-digit student loan debt -- instead choose fields where they can make more money or have more flexible schedules.
Among doctors and medical students, the rigors and sacrifices of primary care medicine are well known.
"Primary care is one of the most complex and demanding fields," said Mary Maddux-Gonzalez, chief medical officer for the Redwood Community Health Coalition, a network of 17 community health centers in Sonoma, Marin, Napa and Yolo counties. "There's the medical school debt and low Medi-Cal reimbursement rates, and then you're asked to provide a full scope of practice to patient populations that vary widely."
In Sonoma County, patients and providers are feeling the pinch. With about 70,000 people who became newly eligible for coverage on Jan. 1 after the rollout of President Barack Obama's Affordable Care Act, county health officials say the demand for doctors far outweighs the supply.
Nearly four times as many primary care physicians are needed than are practicing in the county today, according to a recent study by the county's Department of Health Services and the Sonoma County Medical Association.
Sonoma County has 488 primary care physicians, and health officials say the county needs 2,331 to meet the needs of its 495,000 residents.
The problem is mirrored throughout the state and across the nation. In California, all 58 counties are experiencing a primary care doctor shortage to some degree, with rural areas suffering the biggest shortfalls.
The problem is getting worse as millions of Americans become newly eligible for health coverage and seek care. The country is projected to be short 45,000 primary care doctors from what it will need in 2020, according to the American Association of Medical Colleges.
"Producing enough future primary care physicians is absolutely a challenge," said Andrew Bindman, a physician and professor at UC San Francisco who has studied doctor shortages. "Part of my concern is the number of new people coming into the field to replace those who are retiring."
Even as enrollment in medical schools nationwide is on the rise, Sonoma County's physicians are retiring at a faster pace than students graduate and enter the field.
According to a county survey, 20 percent of primary care doctors plan to retire in the next five years, and an additional 9 percent said they had plans to move out of the county in the same period. About 54 percent of doctors in the county are in specialty care, according to the county survey. The remainder are in primary care.
The shortage comes at a time when the need for primary care doctors is rising faster than any time in recent history. Baby boomers are aging, and their health needs are growing more acute.
"The shortage is getting worse over time," said Maddux-Gonzalez, a former Sonoma County health officer. "If you project out how our population is aging, with increased prevalence of chronic diseases combined with the expansion of health insurance, you can see what we're facing."
Health care reform has expanded access to care for a population that has largely gone uncovered, many for their lifetimes. But having insurance has not necessarily helped alleviate problems for patients who have struggled to find a doctor and secure appointments.
Primary care shortages are leading to long wait times for doctor appointments, providers are overpacking their schedules, and patients are rationing doctor visits, according to county studies and local physicians.
"Not getting to the doctor in a timely way can lead to long-term negative consequences," Bindman said. "Someone who may have presented with an earlier stage of cancer could experience delays, and that could lead to spread of the cancer, for example; or someone with an infection that could have been treated with an antibiotic pill at home could have to now be hospitalized."
The shortage has hit low-income patients the hardest.
Less than 30 percent of primary care doctors are accepting new Medi-Cal patients, according to the county, forcing many to drive long distances to find an appointment or delay care.
Jan Sonander, a family practice doctor in the county since 1989, said he can take new patients only on a referral basis, and he can't accommodate any more people on Medi-Cal.
"I'm busy," Sonander said. His practice sees about three dozen patients a day, and his medical work often is sidetracked by administrative chores.
"When I'm here we can maybe go up to 40 (patients)," he said.
The shortage presents a major stumbling block for health care reform, which has as one of its cornerstones expanded access to primary care. Already, roughly 1 in 4 people countywide receive their medical care in a clinic setting, and that figure is rising, according to Maddux-Gonzalez.
Local health care experts say Sonoma County has been well served by the 76-year-old Santa Rosa Family Medicine Residency, sponsored by Sutter Medical Center. It admits 12 medical school graduates into the program each year. Nearly 80 percent of those doctors stay in California, and 35 percent stay in the county.
Still, local demand for family practice doctors continues to outstrip supply.
The new fast-track medical school seeks to help chip away at the problem, seeding graduates throughout California. Texas, Georgia and New York have similar three-year medical schools.
The new degree allows students to skip the fourth year of school and go right into a residency program either with UC Davis or Kaiser.
The program is backed by a $1 million grant from the American Medical Association.
Tonya Fancher, associate professor at the UC Davis School of Medicine and a teacher for the new program, said it seeks to emphasize the positive impact that primary care doctors can have in a community.
"Traditional medical schools don't give students a good sense of what that is," she said.
Rodriguez, whose grandfather was a patient at Alliance Medical Center in Healdsburg, said she plans to return to Sonoma County when she finishes school.
"I've always known that I want to go into primary care," she said. "I would love to come back to Healdsburg and work in a similar type of clinic setting. That's where I feel I could make the most impact."
You can reach Staff Writer Angela Hart at 526-8503 or firstname.lastname@example.org. On Twitter @ahartreports.
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