California Primary Care Physician Shortage

An insufficient workforce of primary care providers in California has serious implications for long-term health outcomes.

Introduction

Those in healthcare are likely aware of the fact that the United States has a shortage of physicians. To others, especially in California, it may come as a surprise to find out that 44.8% of Californians have inadequate access to primary care physicians (PCPs). Further, it's estimated that the state will be short 4,700 PCPs by 2025 and 4,100 PCPs by 2030. These statistics are obviously concerning as primary care is absolutely essential to manage patients' chronic diseases, appropriately refer to specialty providers as indicated, provide preventive screenings, and partner with patients long-term to help them fully achieve optimal health.

To provide an example, cardiovascular disease, which is the leading cause of death in the United States, can be detected earlier by screening methods such as lipid panels checking for high cholesterol. Early detection and intervention, like prescription medications known as statins and diet/exercise counseling, have been shown to improve outcomes and ultimately save in healthcare costs by avoiding hospitalizations and treatments for more advanced disease. Individuals who live in areas with shortages of primary care physicians have increased barriers to accessing these important healthcare services and are thought to have increased likelihood of poorer health outcomes. Unfortunately, these communities in primary care shortage areas often also have other interrelated factors contributing to poor health outcomes, such as poverty, low health literacy, and lack of health insurance.


Data Sources

The data for the following maps was taken from California Health and Human Services Geospatial Data on the California State Geoportal. The data is divided amongst the 268 Medical Service Study Areas (MSSAs) in the state of California. One of the data fields is primary care shortage area (PCSA) score, which was calculated by taking into account: 1. the percentage of the population in the MSSA under the federal poverty line and 2. the provider to population ratio. In this calculation, nurse practitioners (NPs) and physician assistants (PAs) are counted as 0.75 for every 1 primary care physician due to scope of practice laws. The sum of these parameters is the PCSA score and can range from 0-10. The more significant PCP shortage in the area, the higher the PCSA score.

Another source of data used to evaluate the primary care physician shortage in California is taken from the California Health and Human Services (CalHHS), which provides locations of licensed and certified healthcare facilities. From this data, facility type was filtered to include only primary care clinics.

The last important indicator of healthcare access used in this study was mentioned earlier: coverage with health insurance. Through AGOL Living Atlas, data containing the percentage of the population without health insurance can be found. This data is provided by the American Community Survey (ACS.) The percentage can be broken down (from smallest to largest area) by tract, county, or state.

Maps

Map 1: PCSA Score by MSSA in Southern California

PCSA score in each MSSA can be visualized on Map 1 by shading of the respective area. The higher the PCSA score, the darker blue the region will appear. The lower the PCSA score, the lighter the region will appear. As was mentioned earlier, areas with a larger PCP shortage have a higher score. Here, it is seen that generally the more inland and rural the MSSA, the higher the PCSA score with some exceptions of certain parts of Los Angeles and San Diego counties.

Both PCSA scores and locations of primary care facilities in Southern California are shown in the following map.

Map 2: PCSA Score by MSSA with Licensed Healthcare Facility Locations

Map 2 shows the CalHHS location data for licensed and certified primary care clinics in relation to MSSAs of varying PCSA ranges. Generally, we see more primary clinics in the lighter blue areas of lower PCSA scores, which would be expected. This is not always the case, however. For example, South Central Los Angeles has a relatively dense aggregation of primary care clinics, but also has PCSA scores on the higher end. This could be in due in part to the dense population of these areas or other barriers to healthcare access as mentioned earlier, such as poverty or health literacy.

In the following Map 3, we can visualize the degrees of proportional uninsured population by tracts. Tracts are smaller areas than counties or states and will be used to visualize more precise locations in relation to nearby primary care clinics.

Map 3: Health Insurance Coverage in California Counties with Licensed Health Care Facilities Locations

In Map 3, we see a lot of primary care clinics condensed in cities with larger populations, like San Diego. In the following Map 4, a "summarize within" analysis was ran through ArcGIS Map Viewer to display the amount of clinics per county. The larger the pink dot, the more clinics the county has. This layer was then combined with the health insurance coverage layer to better visualize the amount of clinics compared to health insurance coverage proportion by California Counties.

Map 4: California Counties by Amount of Primary Care Clinics

It is even more clear from this map that some of the counties with the highest proportion of uninsured individuals have the fewest number of primary care clinics. One example is Mono County, with 14.7% of the population being uninsured. This can be compared to Los Angeles County, with a much higher amount of clinics, with 9.0% of its population being uninsured. Part of this is to be expected, as the population is much larger in Los Angeles County.

This does not negate the fact that there is a large access to care problem for patients in these counties with lower amounts of clinics. There may not be motivation for primary care physicians to open clinics in these more rural areas with a high amount of uninsured patients, with concerns for not receiving payment for their services. One idea to potentially address this is to give more government funding and financial incentives to PCPs, PAs, and NPs to practice in these underserved areas.

What these findings also display is that the designation of parts of urban cities like Los Angeles and San Diego as primary care shortage areas with high PCSA scores is not necessarily due to a lack of PCPs and primary care clinics, but likely more related to other factors like lack of health insurance, transportation, and lower health literacy.


Survey

The following survey could be used to provide a general baseline and an idea of barriers to access of primary care services among participants. Please feel free to submit your own responses.

ArcGIS Survey123

The following are survey results as of 12/14/2023:

Most participants had primary care services 0-2 times in the last 5 years.

81.82% of participants stated that they did not pursue medical services they felt they needed in the last 5 years.

Transportation and lack or knowledge on finding a PCP are among the top reasons for why participants did not seek primary care services.

Average age of survey participants: 54.7 years

Map 5: Survey Participant Locations


Conclusion

It is important to assess access to primary care using tools like surveys in order to understand the barriers individuals may face towards receiving primary care, which is important for managing and screening of chronic diseases and reducing healthcare cost. As we saw earlier, primary care shortage areas may not always be due to a lack of primary care providers in the immediate area. Interventions to increase access for these individuals in addition to those without health insurance and in rural areas without primary care clinics will be imperative to the future of California's health outcomes. Potential interventions to explore are increasing incentives for medical students to become primary care physicians and offering incentives for primary care providers to open clinics in rural areas with less health insurance coverage.

This story map was created for the final project for CGH 315 at Claremont Graduate University.

References

Most participants had primary care services 0-2 times in the last 5 years.

81.82% of participants stated that they did not pursue medical services they felt they needed in the last 5 years.

Transportation and lack or knowledge on finding a PCP are among the top reasons for why participants did not seek primary care services.