Part of a series.
Since the Covid pandemic began, the need for pulmonologists, the doctors who specialize in lung care, has soared in Shasta County. That’s a huge problem because Shasta County, like many rural counties across America, is experiencing a serious shortage of pulmonologists and the many other kinds of physician specialists who treat specific medical diseases or parts of the body.
Shasta is part of California’s vast North State area, which has significantly worse health care access than the rest of California. The barriers to treatment are even higher when residents try to access care from specialist physicians. Without enough neurologists to treat Parkinson’s disease, rheumatologists to treat arthritis or orthopedists to provide bone surgery, many patients lack the ongoing specialty care needed for their chronic or acute medical conditions.
Tara Ray, who asked that her real name not be used for this story, is a 24 year old who’s been living with a chronic medical condition since childhood. She says her medical care requires ongoing visits to a rheumatologist, but as someone living in Shasta County, she has found accessing specialist care almost impossible.
“So much energy goes into seeking care once you are referred to a specialist out of the area,” Ray said. “How far away is the specialist? Do you have a car? A license? A family member who can take the day off work to drive you? Is your gas tank full? Can you afford to take the day off work yourself? Will you require down time after the trip to recuperate?”
Complex social factors that affect medical care mean Ray and others may fail to receive the ongoing care needed to maintain their health and often end up in local emergency departments, clogging up the emergency system and costing significantly more. Even worse, many of these patients don’t reach ERs until their health has become a crisis, leading to an increase in hospitalizations and longer stays, at still higher financial and societal costs.
Because of the physician specialist shortage, Shasta County patients with uncontrolled but routine health conditions, such as asthma or chronic obstructive pulmonary disease (COPD), may be referred to medical centers like UC Davis where they’ll have to travel hours for care.
For this story, Shasta Scout interviewed more than a dozen nurses, doctors, and administrators serving the Shasta County area and beyond. All agreed that the lack of medical specialist physicians in rural areas is an ongoing and significant problem that worsens not only medical outcomes but public health outcomes.
When patients or families experience difficulties accessing needed medical care or have to take time off work and travel long distances to access it, it serves as a multiplying factor to existing social needs, increasing patients’ risk of things like substance use, housing uncertainty and domestic violence, these sources unanimously agreed.
Dr. Paul Davis is chief of medicine for the Redding Rancheria Tribal Health System, which includes four clinics and serves both Native and non-Native patients. He says lack of access to physician specialists is a problem that staff at the health center face every day. In September, Davis said, the clinic he works at lost its orthopedic specialist to retirement, leaving Rancheria patients with time-sensitive orthopedic injuries like broken bones with few options.
As the medical director of Neonatal and Newborn Services at Mercy Medical Center, Dr. Ashlee Smith said she also sees how the rural nature and low incomes of Shasta County affect patients and families every day. Smith runs the only NICU north of Sacramento and south of Medford, Oregon, where babies who need intensive care may be admitted for anywhere from a few days to a few weeks.
Outcomes are far better in NICU patients if families are able to be near them during their stay, Smith said, but many lack simple necessities like gas money to drive from, for example, Cottonwood to Redding to visit their babies in the NICU, a distance of about 20 miles.
“A lot of them have several other children at home with no one else to help, or only one car. We see pretty much every barrier (to good health care) that you can imagine,” Smith said.
A Shortage of All Kinds of Doctors
It’s always been harder to bring doctors to rural areas like Shasta County, said Dr. Dean Germano, CEO of the nonprofit Shasta Community Health Center (SCHC). But factors including wildfires and the Covid pandemic, which convinced many aging physicians, including specialist physicians, to retire early, have worsened that shortage.
“Over the last 5-10 years, some real holes (in the system) have developed,” Germano explained, “and over the last several years it’s been horrendous.” Recent numbers shared by a local hospital indicate an overall physician shortage of about 70 doctors county-wide, he said, including both primary care physicians and physician specialists.
Primary care doctors provide the first line of care for their patients when infections emerge, influenza worsens or joints ache. Their care is essential to patient health, but they’re also generalists, trained to do a little bit of all kinds of medicine well, but not trained to handle the intensive specifics of various body parts and diseases. When patients’ needs exceed their scope of care, primary care doctors refer the patients for neurology, rheumatology or psychiatry, among other medical specialties, for the in-depth medical care that’s needed to help assess, manage or resolve illness.
The lack of both kinds of doctors has a compounding effect. As primary care doctors struggle to get their patients into specialist care, they’re left managing health conditions they weren’t trained to treat, worsening their stress and liability, extending their patient loads and wait times, and reducing their overall quality of life and satisfaction in their careers.
Costs and Social Climate Cause Shortages
California’s rural North State comprises about a fifth of the state’s geographical area, but makes up a relatively small percentage of its overall population. That population is also unevenly distributed, worsening health care disparities.
Redding, which is home to more than 50 percent of Shasta County’s population, has two hospitals, but state mapping resources indicate that much of Shasta County and the North State consists of “frontier” areas when it comes to health care access, says Lisa Pruitt, a professor at University of California, Davis School of Law who specializes in rural issues. Outside of Redding, Shasta County averages only 23 people per square mile, and many areas of the county have far fewer, making the county “more rural than rural,” she explained.
That matters because “rural counties are usually older, sicker, poorer,” says Doreen Bradshaw, executive director of the Health Alliance of Northern California (HANC), which works with federally qualified health centers at 30 clinic sites across more than 25,000 square miles of Northern California to support delivery of primary care in rural and frontier areas. She says more than one-third of Shasta County residents are on Medi-Cal, the state’s Medicaid program, which offers free or low-cost government health coverage for California residents who meet eligibility requirements.
High numbers of Medi-Cal patients and low Medi-Cal reimbursement rates contribute to the complexity of providing rural health care, she and others said. Physician specialists in private practice tend to group around urban teaching hospitals where they’ll find the private-pay patient load needed to pay off often-huge medical school loans.
“It’s not that nobody cares about specialists in far-flung areas, it’s that nobody cares enough,” Pruitt, of UC Davis Law, explained. “Here’s the thing, it’s expensive. As a political matter, anytime you’re providing any service to a rural area you struggle to achieve economies of scale because there aren’t very many people and they’re spread across the countryside. If you’re going to commit to providing that service in a rural place, it’s going to cost more per person. And governments tend to be very committed to cost-benefit analysis.”
Shasta County’s deeply conservative social and political environment also makes it more difficult to attract and retain doctors, including specialists, Germano said. “I think one of the biggest challenges is the physicians’ or specialists’ consideration of whether this is a place they want to live,” he explained, saying that it’s particularly important to remember that around 30 percent of physician specialists come from the international community and are often people of color.
Fixing the Specialist Squeeze
California gubernatorial candidate and state senator, Brian Dahle, who represents the North State, echoed much of what locals said about the specialist problem, its causes and long-term solutions, saying he’s been working on this problem for the last 10 years. New laws might help, he said, but they still have to make sense financially, which is difficult given the complex factors that contribute to the problem. “We have to shine a spotlight on this,” he said, “and figure out a way to help our people.”
Coordinated statewide assessment could be a start. While California data shows Shasta County lacks primary-care doctors, Germano and Bradshaw both said they are unaware of any statewide planning or policies to respond to the lack of specialist physicians in rural areas, or to the worsened health and social outcomes and increased societal costs caused by this scarcity.
“No one watches for distribution of specialists statewide,” Germano said. “Statewide they acknowledge the shortage, and foundations do studies … but there is no central planning division that says we’re going to do everything possible.”
That lack of central planning is one reason no one Shasta Scout spoke with knew exactly which or how many specialist doctors are missing in Shasta County. Figuring that out is complicated by rapid turnover in the physician workforce, Bradshaw said, mentioning a local hospital’s 2016 study to identify existing physician specialists, which quickly became outdated when many of the specialists left the area shortly thereafter. Germano agreed, saying it seems like he gets a different list of specialist shortages every week.
But in the midst of such need, local collaborators continue to develop and implement a variety of short- and long-term solutions. At Shasta Community Health Center, Michelle Carlson is a center manager for psychiatry, specialty care and telemedicine. She says it’s extremely difficult to keep up with patient access needs because the center makes hundreds of patient referrals every day.
To do so, the center has increased telehealth services through its telemedicine center, which provides real-time video calls with physician specialists via a screen rolled into the patient’s room. Since the pandemic, telemedicine has grown rapidly, she said, and has provided new access to care for some of the patients falling through the cracks in the system.
The health center also contracts with a variety of private-care physician specialists to come to the center a half day or more each month to see patients. Many come to help because of Germano’s extensive networking efforts, she explained, and their recognition of what he’s hoping to accomplish at the center, which serves approximately 40,000 patients and does not deny care due to lack of finances. The reimbursement of these specialists varies, but money isn’t their main motivation, according to Carlson, who explained that many are mission-driven people who just really want to help with the overwhelming need. “They get paid,” Carlson said, “but not as much as they would in private care.”
She said being able to see a specialist on site helps because of all the psychosocial issues patients have, including low income levels, transportation and the distance to find other specialty care. SCHC has been seeing specialty patients from other counties, including as far as Humboldt County, for years, due to the lack of resources in these counties for patients who have Medi-Cal/Partnership.
Finding long-term fixes requires widespread collaboration, and the Shasta Health Assessment and Redesign Collaborative (SHARC) is working to identify needs. So far, the organization sees medical workforce shortages as a primary problem. “The recruiting challenges are immense,” Bradshaw said, “and they’re at every level of the medical workforce.”
SHARC has brought together local educational institutions through a program called Shasta Health Rockstars, which recruits individuals to the medical workforce beginning in high school and recognizes local medical providers’ careers to promote their value to the community.
At Germano’s health center, he’s using a similar pathway with medical scribes, individuals who help doctors document patient care in real time, by providing ongoing education and special support to help them move towards medical school. It’s one aspect of the larger connections between those working to recruit and retain the North State’s medical workforce and the University of California, Davis.
Another important university connection is a family practice medical residency that annually brings between 8-10 medical students to the North State, where Germano and Davis hope they can convince them to stay and practice. Statistically, having the residency here will help, Davis said, because most doctors end up practicing within 250 miles of where they’ve done their residency.
The pipeline plan seems to be slowly working, both said. Many doctors at both SCHC and the Rancheria have come to the area via the residency program. Last year, four of the residents committed to staying and practicing locally, Davis said, contributing to long-term solutions to an intense and complex local problem. “That residency is why I’m here,” said Davis, who has been practicing medicine in Shasta County now for over 25 years after coming to the area from Orange County. “If it wasn’t for this residency we’d be in a lot worse of a situation.”
But there’s still a very long way to go. As part of the California Future Health Workforce Commission, Germano is working with other leaders across the state to find ways to solve the complex problems California’s rural populations face. He says the CFHWC has estimated it will take $3 billion to address the commission’s top 10 priorities for building California’s workforce, including improving rural health care access to psychiatrists and other physicians.
Germano explained that new state policy is also needed, saying lawmakers could fund expanded medical residency training programs like the one in Redding, to ensure they include specialist training. The government could also set up loan forgiveness programs for specialty physicians who work in rural and underserved regions, and compensate them based on Medicare rates, not Medi-Cal rates, he said.
Conversations about lack of specialists come up regularly with others who serve with him on the board of the nonprofit Partnership HealthPlan of California, which manages Medi-Cal for 14 California counties, Germano said. Finding solutions to the lack of specialty care is in everyone’s best interest because more specialists would reduce medical complications, costs and social risks.
“I’ve seen how (traveling for specialty care) really taxes and stresses a family that may be already on the edge,” Germano said, “and it’s not in anyone’s interest to see a child or family fall apart.”
CORRECTION: An earlier version of this story stated that most physicians wind up practicing medicine within 50 miles of where they did their residency. The actual distance is 250 miles.
This reporting is part of a collaboration with the Institute for Nonprofit News, Shasta Scout, The Daily Yonder, Carolina Public Press, and Honolulu Civil Beat. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.