Health & Medicine

Strapped for doctors: California’s rural clinics backlogged with Medi-Cal influx

Glenn and Janelle Ransom of Brownsville, right, leave after their appointment as Dr. Celia Sutton-Pado welcomes her next patient, Leland Pauly, 90, who has lived in Camptonville his whole life. On the first Tuesday of every month, the Western Sierra Medical group sends a mobile health clinic to the community resource center in Camptonville. The shortage of rural health care providers is exacerbated as more and more people enroll for coverage after the Affordable Care Act.
Glenn and Janelle Ransom of Brownsville, right, leave after their appointment as Dr. Celia Sutton-Pado welcomes her next patient, Leland Pauly, 90, who has lived in Camptonville his whole life. On the first Tuesday of every month, the Western Sierra Medical group sends a mobile health clinic to the community resource center in Camptonville. The shortage of rural health care providers is exacerbated as more and more people enroll for coverage after the Affordable Care Act. lsterling@sacbee.com

Once a month, a sleek white bus outfitted with supplies from Western Sierra Medical Clinic rolls into Camptonville, a former miners’ town on the outskirts of Plumas National Forest. It passes a cluster of red barns that house every school classroom in town, as well as Burgee Dave’s at the Mayo, the only restaurant.

The bus pulls into the driveway of the Camptonville Community Center, a squat concrete building where typically several people already are waiting. For many, the bus is their only chance to receive prescriptions, have a nagging cough checked or receive other medical care. The next closest option is a small clinic in North San Juan, a town 13 miles down slow and windy Highway 49.

The rapid expansion since 2013 of Medi-Cal, the state’s insurance plan for low-income residents, has ushered in a bittersweet new reality for rural areas such as Camptonville, where many residents are older and sicker than their urban counterparts. The changes brought about by the Affordable Care Act mean thousands of rural residents who never had insurance are connecting with health care for the first time. But that newfound demand has only added to the wait times for urgent and routine care in rural communities that already were short of physicians and clinics.

Patients have tried to get around the practitioner shortages by seeking out mobile clinics and accessing care across state lines, while rural health care providers are scrambling to recruit more doctors. Some are experimenting with alternatives such as telemedicine, which connects patients to care miles away via video conference.

“There’s much more demand than there is supply,” said Doreen Bradshaw, executive director of the Health Alliance of Northern California, a consortium of 10 clinics and health centers, mostly in rural areas in the state’s far north. “When you look at the overall health status of Northern California residents, it’s much poorer than the state. ... We don’t want them to be in the emergency room. And we don’t want them to wait.”

The Western Sierra Medical Clinic bus rolls in with basic services: a doctor, medical assistant, small exam room, and needles and other supplies.

On a recent morning in Camptonville, Jois Marbut, 69, was waiting her turn at the bus with her charred feet resting on a folding table. A serious childhood burn left them scarred and sore, a problem that has worsened with age and scoliosis. With her primary care physician 27 miles away in Grass Valley often booked, she counts on the monthly bus visit to get her ailments checked out.

When you look at the overall health status of Northern California residents, it’s much poorer than the state.

Doreen Bradshaw, executive director, Health Alliance of Northern California

Marbut has been on Medi-Cal most of her life, but getting seen by a doctor has become more difficult in the past two years as the Affordable Care Act has brought more people into the program, said Lisa Case, a friend waiting with her for the mobile clinic. When Marbut moved to North San Juan two years ago for peace and quiet, it took her 18 months to find a primary care physician who was accepting new patients, she said. Marbut still hasn’t found a nearby chiropractor or rheumatologist who takes her insurance.

“I feel like I’m dying on my bed – I don’t like it at all,” Marbut said. “I’ve kept in shape as much as possible, but this is keeping me down.”

State data show about 2.7 million patients have enrolled in Medi-Cal since 2014, and that influx has shrunk the ranks of the state’s uninsured and slowed the rise of insurance premiums. Yet it’s also exacerbated problems in 214 “doctor deserts” statewide – places with only one physician for every 3,500 people. That compares with one physician for every 1,000 people, on average, statewide, and one for every 1,500 in the Sacramento area. Approximately three-quarters of the so-called deserts are in rural areas of California.

Rural living, with all its charms, is also associated with some troubling health patterns. The suicide rate in California’s rural counties is rising twice as fast as the rate in its urban centers, according to California Department of Public Health data. The trend has been tied to isolation, substance abuse and access to firearms, and is more pronounced among older, white adults.

“Boredom sometimes leads kids to pick up cigarettes, have a drink, have excessive behavior – and sometimes that never stops,” said Cathy LeBlanc, a longtime Camptonville resident. “That’s just the sad part.”

For specialized medical care – or even a trip to a major retail or grocery store – Camptonville residents trek through the foothills to Grass Valley or Nevada City. Without any public transit, seniors who don’t drive or have someone to give them a ride have difficulty making the trip.

“Patients have to travel quite a few hours just for basic services,” Bradshaw said. “When that travel is difficult, sometimes they just don’t go.”

Those same isolating conditions also make it harder for health officials to lure doctors to practice in small towns, where they typically earn less than what major urban medical centers pay.

There’s a lot more competition than there ever was before. You combine that with all these new people with coverage and it’s like the Wild West of medicine out here, in terms of recruitment.

Dean Germano, CEO, Shasta Health Center in Redding

Shasta Community Health Center farther north in Redding just completed a $10 million, 20,000-square-foot expansion to accommodate new patients brought in by health care reform, with a sleek new third floor and 30 additional exam rooms.

All it needs, said CEO Dean Germano, are enough doctors to treat the swarms of new patients who have started coming to the center in the past three years. In particular, it needs primary care clinicians, and more specialists in services such as radiology and mental health counseling guaranteed under new insurance plans.

The center’s employees earn on average $70,000 compared with, for example, $95,000 at UC Davis Medical Center in Sacramento, according to the job website Indeed. Many medical residencies are also based in urban areas, and graduating physicians tend to practice near where they train.

“The (Affordable Care Act) was kind of the shock factor that drove up the demand, but these individuals have always been in our community,” Germano said. “It’s not like they were dropped from Mars with an insurance card. It’s up to us to make the changes.”

In 2014, Germano began turning away new adult Medi-Cal patients at his main facility as waiting lists grew and physicians became overloaded. “We just couldn’t keep bringing in new patients and not do a disservice to the patients we already have,” he said.

With many rural physicians reaching retirement age, the quest for “new blood” has become increasingly dire.

“There’s a lot more competition than there ever was before,” Germano said. “You combine that with all these new people with coverage and it’s like the Wild West of medicine out here, in terms of recruitment.”

In North San Juan, south of the Yuba River, Dr. Peter Van Houten is finding creative ways to navigate the patient-physician imbalance in his small family clinic. He has taken some of the load off his three primary care physicians by giving more responsibilities to physician assistants, nurse practitioners and other support staff.

He’s also hired a case manager to work with patients on housing and employment needs so they can stabilize their lives and get healthier. And he’s been relying more heavily on telemedicine for mental health services, which frees up his psychologist and two clinical social workers to see more patients in-house.

Still, wait times for an appointment with a doctor at Van Houten’s clinic run about three months. And Germano and Van Houten come up empty-handed when it comes to critical specialties such as neurology, oncology and nephrology – a problem that isn’t likely to be resolved until the state and federal governments allocate more funding to rural residency programs.

“Everyone’s kind of running as fast as they can,” Van Houten said. “I just wish we had more places to put every single patient we’d like to get in.”

Sammy Caiola: 916-321-1636, @SammyCaiola

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