For much of 2017, healthcare has dominated the headlines. But while access to insurance coverage remains a national debate, here in the San Joaquin Valley, getting to see a doctor isn’t always easy, even for people who have coverage. It’s not a new problem, and it’s not unique to the valley, but this area is especially hard hit by a lack of physicians. This story kicks off Struggling For Care, a new series about doctor shortages produced as part of a project with the USC Annenberg School of Communication and Journalism’s California Health Journalism Fellowship. Over the next four weeks we’ll bring you stories about the problem and some potential solutions. Today, though, we begin with those who are most affected by the doctor shortage, and hear how disparities and trends at the local, state and federal level are leaving the Valley behind.
Christina Bellotta is a flute teacher. This gig in a little rehearsal room at Fresno State is one of her two part-time jobs.
Bellotta needs the flexibility of part-time work, because a few years ago, she was diagnosed with bipolar II disorder—a variation of the manic-depressive mental illness that involves more depressive episodes than manic ones. “So I have the chronic fatigue and the general feelings of darkness and it's difficult to find energy sometimes to even get up—and that is depressing,” Bellotta says.
She’s learned to manage her disease with therapy and medication, but she still has ups and downs and occasionally needs to cancel a lesson.
Last year, though, Bellotta needed a lot more flexibility than she had anticipated. She was searching for a new psychiatrist. She’s on Medi-Cal, and the only in-network option she could find who was accepting new patients couldn’t fit her in right away. Her prescriptions ran out and she was off her meds for weeks. “The light was really painful, and I was shaking a lot, and I just felt sick,” she says. “It was hard to keep going to work, and keep teaching lessons, and pay bills, pay attention to anything.”
Even with her previous psychiatrist, Bellotta had been driving from Clovis to Kerman for her appointments—close to 30 miles each way.
What Bellotta experienced was textbook doctor shortage: Offices closed to new patients, long wait times, and far driving distances. Some patients can’t afford the transportation time or costs, and end up instead in emergency rooms. All this in a region with an outsized need for medical care, because of oppressive air pollution and ballooning rates of chronic disease like obesity and diabetes.
Dr. Sanjay Srivatsa is an internist and cardiologist in Fresno who’s troubled by patterns he’s seeing in this physician underserved area of California. “When you have so much burden of disease, it is nobody's fault, but there isn't enough people to take up the slack,” Srivatsa says.
Physician scarcity is a growing national problem. By some estimates, the entire country could be short of at least 40,000 doctors by the year 2030. But when it comes specifically to primary care, California already trails national recommendations for doctors per capita. And, according to Janet Coffman, a professor of health policy at the Healthforce Center at UC San Francisco, the problem is particularly pronounced here. “The San Joaquin Valley has one of the lowest ratios of primary care physicians and of specialist physicians per population for any region in the state,” Coffman says.
For every 100,000 residents, the federal government recommends a supply of 60-80 primary care physicians. Across the Valley, we have an average of 39. The Bay Area, on the other hand, falls within that recommended zone, with twice as many primary care physicians per capita as the Valley’s most impacted counties. “It's sad,” Coffman says. “It's like many things: In the Bay Area there's an abundance, and when we look at the heartland, you know, the fruit and vegetable basket of the nation, it's very sad and troubling.”
So why such a disparity here? It’s easy to blame the region’s poor reputation for scaring away new doctors, but the answer is much bigger. And it’s an old problem. Dr. Michael Peterson is chief of medicine and associate dean of UCSF Fresno, a residency and fellowship program created about 40 years ago. “The rationale for placing us here in 1975 was: This was a growing area of California and it was a physician underserved region of California,” he says. “So this is not a new problem.”
Yet despite decades of attention, the Valley still lacks doctor training. There’s no medical school between UCLA and Stanford, and a federal law actually limits the number of graduate residents that hospitals can take on.
There’s also the matter of geography. Nationally, urban areas tend to have 33 percent more primary care physicians than rural ones. “If we look at the Central Valley, and then you say, well, how many of those physicians are in Fresno or Clovis, and therefore not really benefitting the patient population in Porterville and Hanford, it's a significant number,” Peterson says. “So the smaller communities and the rural communities have the worst shortages.”
Consider, too, how providers are siloed into insurance networks. A doctor you need may practice down the street from you, but she may not accept your insurance. That problem is particularly pronounced for patients on Medicaid, or Medi-Cal as it’s known in our state. California doctors who see Medi-Cal patients get paid less than in almost every other state in the country. That’s one reason a quarter of Valley doctors don’t accept Medi-Cal patients at all. “Those physicians that are choosing not to take Medi-Cal are not bad people,” Peterson says. “These are people that recognize that it's not a sustainable model for me to do that.”
These forces are not limited to the Valley. But they converge here. “The 50% of the population being Medi-Cal and the reimbursement rates that we deal with in California and specifically within the Central Valley all sort of couple together to make this the perfect storm,” Peterson says.
How many primary care physicians are in your county? Check out this infographic from the California Health Care Foundation.
Christina Bellotta blames Medi-Cal for a lot of her frustration. She wonders if she’d have been treated this way if she were paying for private insurance. “No one cares about you, you cost too much, you're too inconvenient, you don't contribute enough to society for us to care about you,” she says. “That's what it feels like.”
More than a year after her ordeal, Bellotta’s settled into a new psychiatric routine with the help of Fresno County. It’s an approach health officials are using to fill in gaps in care. “The doctor that I see, I talk to him through a computer screen, and he practices in Florida,” she says.” So it's not perfect, there isn’t a live person that I can interact with,” but it works. For now. A sentiment begrudgingly echoed by many Valley residents.
So, why haven’t we fixed this problem yet? And what else is being done about it? Answers to those questions in later stories, starting with the 20-year-old federal law that hamstrings our teaching hospitals.