Lupe Alonzo-Diaz, Physicians for a Healthy California: The Doctor Shortage Is About More Than Numbers

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

Today I’m happy to welcome a leader in California’s healthcare workforce community, Lupe Alonzo-Diaz, the President and CEO of Physicians for a Healthy California. PHC is on the forefront of advocating for improving community health, growing a diverse physician workforce and promoting health equity in the Golden State.

I’m looking forward to learning more about PHC’s overall mission, the specific efforts it is making to address the state’s physician shortage, and getting some highlights from its recent Health Equity Leadership Summit. We’ll also be getting a preview of an upcoming report on physicians who are women of color. Thanks so much for joining us today, Lupe.

Lupe Alonzo-Diaz: Thank you, Van. It’s a pleasure to be here and chat with you today.

Van: I’m delighted to have you here. Well, let’s begin by having you share a little bit about your personal journey to become president and CEO of PHC, and also if you could give us an overview of PHC and how you define your mission.

Lupe: Absolutely. And again, thank you for the opportunity to chat with you this morning. As you mentioned, the core mission of Physicians for Healthy California is advancing community health, growing a diverse physician workforce and promoting community health. All of those things are part of my own personal journey.

I am the daughter of Mexican immigrants who came to this country undocumented. I am a mother of an autistic child. I like to say that I live in the corner of privilege and injustice. The privilege comes from having been born here, being able to speak English, having advanced health literacy, having a wonderful career with wonderful health insurance, and the ability to take time off work. That’s the privilege and that’s the space that I sit in. I also sit in a space of injustice. Both of my parents came to this country from Mexico, and worked pretty much their entire adult lives here. They both retired. They had limited health insurance, and in fact, most of them had public insurance.

So, I have directly the experience of having to advocate for my mom and her ability to access health care. She doesn’t have a pension, and she really relies on Medicare in order to ensure that she has access for her health care needs. I like to say that I am her data analyst, I am her insurance adjuster, I am her advocate, I am her scheduler. So, that’s one side of the experience.

The other side of my experience is as a mother of an autistic child, and I recognize my privilege in recognizing that when I go seek services — both educational, clinical and other mental health services for my son — I’m oftentimes told that I should feel lucky, that his autism isn’t as “advanced” as for other children. Oftentimes, my experience as a mother has been one in which — very similar to being a daughter — I am advocating for increased access to services.

I am reviewing insurance forms, ensuring that he qualifies for services and it’s really challenging, difficult, and exhausting. It’s not a function of time. It’s a function of really wonderful people who work in the system — that includes physicians, nurses, x-ray technicians, case managers — really wonderful people that work in a system that’s incredibly complex.

So, when I talk about living in the corner of injustice and privilege, it comes from recognizing my own specific journey. It comes from recognizing that that is a journey that I currently live in. It is a space that I currently take. And so my own journey to being the CEO of Physicians for Healthy California comes from the perspective of government exists to solve complex problems that don’t get solved necessarily in the private sector. That’s why we advance public education. That’s why we advance healthy places to live. That’s why we promote increased access to care. We do that because government plays a role in that.

As I have had this journey, both personally and professionally, it was important to me to lead an organization that was advancing and promoting health equity and community health and was really thinking about the role and the space that they want to take in terms of increasing access to care. And not just care, but quality care, culturally dynamic care. So, I am excited to be part of an organization and part of an ecosystem of the larger California Medical Association that is really thinking about all of these issues, not just from a policy perspective, but from a real-life, patient population perspective.

My own journey to being the CEO of PHC comes from the space of wanting to partner with good government, to partner with organizations — public health agencies, as well as other stakeholders — that desire to advance and desire to create a new version, a new futuro, if we can, that really provides culturally dynamic, supportive, quality, accessible care, regardless of where they are. Rather than thinking about the no-wrong-door approach, that it’s a no-wrong-place approach…that it doesn’t matter where we live, it doesn’t matter where we work, that we would still have access to that type of quality care.

Van: So, Lupe, I’m looking at the fact that there’s a shortage of physicians in California expected to reach 10,500 roles by the end of this decade. Ooh, that’s a big number. Can you tell me about the work Physicians for a Healthy California is doing to address this challenge?

Lupe: While California has definitely made a lot of strides with respect to state-of-the-art innovation and medical technology, as you noted, there are still a lot of challenges with respect to access, particularly when we think of the shortage of physicians. The shortage is defined in three different areas. One is numbers. You referenced the 10,500 physicians that are needed by the end of this decade. Another one is geography. Oftentimes, we don’t have enough access to physicians in particular areas — the Central Valley, the Imperial Valley, the Northern Siskiyou areas — there are definitely areas that can and should have access to more physicians and to more access. The last one is diversity, which I slightly referenced. Having enough culturally dynamic as well as diverse physicians.

As an example, although the Latino population in California is almost 40% of the population, about 6% of all licensed physicians in California are Latino. So, when we talk about the shortage, it’s important to recognize both the numbers as well as the geography and the diversity that is critical in order to ensure that we’re delivering high-quality, culturally dynamic care.

There’s two programs that PHC partners on with public agencies in order to advance and increase access to care in those underserved communities. One of them is CalMedForce. CalMedForce is a program that is funded by Proposition 56, which was passed by voters in 2016, and it supports the expansion as well as the recruitment of physician trainees in those underserved areas.  One of the things that we know is that physicians tend to practice where they are training, so the more that we can provide GME or graduate medical education programs in those underserved areas — in the Central Valley, in the Imperial Valley, in the Northern Sierra areas — the more opportunities there are for physician trainees to be exposed to those communities. That might also include street medicine. It can also include a migrant farm worker clinic.

So, the CalMedForce GME program awards physician training programs to ensure that we have that increased access to care. That’s critically important given that, on an average, a physician resident is able to provide care to 600 patients per year. With respect to CalMedForce, we have awarded 500 GME programs a total of $189 million to support 966 physician trainees, including 252 new and 133 expanded residency positions in underserved areas.

Our second program is CalHealthCares. It’s also supported and funded by Proposition 56. It’s a partnership with the California Department of Health Care Services. CalHealthCares advances and increases access to care for Medi-Cal communities. We know that there are a lot of disincentives with respect to providing and participating in the Medi-Cal program, primarily given the low reimbursement rate for Medi-Cal physicians and dentists. CalHealthCares recognizes that in order to increase access to care for those Medi-Cal communities, we need to be creative with respect to how we incentivize physicians and dentists. So, CalHealthCares provides a loan repayment of up to $300,000 in exchange for a five-year service obligation. CalHealthCares specifically targets individual physicians and dentists that have recently graduated from medical school or from dental school, the idea being that we can not only incentivize physicians and dentists to practice with Medi-Cal, ideally we’re helping them to make lifelong decisions about their career in terms of continuing to serve Medi-Cal patients.

We know that supporting physicians in participating in the Medi-Cal community increases access to care, and we see that in different ways. We see it with respect to the diversity of the CalHealthCares awardees. We see it also with respect to the reduction in wait times, as well as just generally the increased access to the number of Medi-Cal physicians. Over the last five years, we have awarded more than 1,000 physicians and dentists a total of $256 million in repaying their debt.

One of the things that’s really fascinating about CalHealthCares is if we step back and we think about the shortage — and we talked about the shortage being from the perspective of numbers, geography, and diversity — one of the fascinating data points around medical education in general is that most physicians graduate with an average of $300,000 to $315,000 in educational debt. Another interesting point is that in the last five years or so, we’ve actually seen more physicians graduate with less educational debt. On the flip side, we’re seeing that those individuals that are graduating with educational debt are graduating with more educational debt.

That tells us that, generally speaking, it is a big ten-to-fifteen-year commitment to go through medical education. And oftentimes, without programs like CalHealthCares — without a scholarship, without a loan repayment — then oftentimes it can be really challenging for individuals from those underserved, underrepresented communities to make a decision to become a physician because that ten-to-fifteen-year commitment results in educational debt of over $315,000.

Physicians tend to pay anywhere between $500,000 to $600,000 over the course of their twenty-year educational debt. So, the goal of CalHealthCares is to incentivize physicians to practice with Medi-Cal. And those physicians, ideally — and based on our awardee data — those physicians come from geographically underserved communities. They also speak a second language and they’re also committed to staying in those communities, just as importantly, after they finish their service obligation.

Van: The CalMedForce and the Cal Health Care program are both doing great things in the community. You shared that the average debt for doctor training is $300,000 to $315,000 and I’ve heard also that average debt to become a dentist is about $250,000. These are, again, big numbers. So, it’s not a small venture for those who decide to go into these fields, and yet our communities need these practitioners to come from their communities to serve the community.

I’m wondering if — given that the audience of this podcast are largely workforce development, economic development, and education leaders — there’s any call to action or requests that you have of them to help the cause?

Lupe: Absolutely. With respect to advancing the cause, definitely one call to action is recognizing that if increasing and if having access to quality, culturally dynamic care is a public good — if that is a value that we hold as society — then we need to invest in those resources. We need to invest in those programs that then advance and produce and address physician shortages, again, not just from the perspective of the numbers — the 10,500 shortage by the end of this decade — but also the geography, ensuring that we have the right mix of physicians and specialists in those underserved areas, as well as the diversity.

When we talk about justice, equity, diversity, inclusion, when we talk about health equity, it’s beyond diversifying the workforce. It’s also about ensuring that the current workforce and that the future workforce is also providing and delivering culturally dynamic care in a way that the community can respond to. We know that from the perspective of social determinants of health, the majority of health indicators and health symptoms and health conditions are really from the perspective of external factors. Those are the determinants of health. It is where people live. It is where they work. It is their journey. It is adverse child experiences. It is all of those things. And so we need to find a way to balance promoting and ensuring that we have a sufficient number of physicians with also addressing some of those larger, broader health equity issues and challenges that our communities face.

Van: Lupe, on the mind of some of our listeners may be the question of whether the shortage in physicians specifically is at a moment in time. Is it cyclical or are there some additional trends, like aging of our population, that is causing the shortage to become greater and greater?

Lupe: That’s a great question. I would say that it’s been a slow but ever evolving and increasing roar. There has, generally speaking, always been a shortage of physicians, again, because at an individual level, it is such a big commitment to make. But you’re absolutely right that as our population becomes more diverse, as it becomes more complex, as it ages, it requires additional training and specialization. So, all of those things matter in terms of how we provide and promote quality graduate medical education, which is why programs like CalMedForce are so critically important.

CalMedForce programs and our awardees are not only expanding the number of physician education training opportunities in those underserved communities, they’re promoting value-based care, they’re promoting a team-based approach, they’re promoting innovation, they’re promoting different opportunities to expand how we deliver that care. Again, whether it’s street medicine, whether those physician trainees are, as an example, doing clinical rotations in migrant farmworker clinics. It is through funding programs that are awarded through CalMedForce that graduate medical education programs have an opportunity to really expand and innovate the way that they deliver medical education.

Van: You mentioned value-based care so let me direct the next set of questions to that as well as primary care teams. These are some trends that are affecting not only the physician, but also the team members who work around them, including the allied health workers, which is a focus of Futuro Health.

I chair the California Healthcare Workforce Education and Training Council and we’re looking into how things are shifting to primary care teams. Can you share any insights into how this will impact the needed skill sets, especially of the nursing and allied health workforce that work with and around the doctors?

Lupe: Sure. Some physicians have been practicing in team-based environments for decades, whereas for others, the team-based approach may be a new way of practicing. Achieving the highest quality care at the lowest cost possible while improving patient outcomes and challenges that we’ve discussed — such as aging populations, chronic conditions that are becoming more prevalent, as well as newly insured patients entering that health system — physician-led and team-based care approaches can achieve those goals. It is, again, programs like CalMedForce as well as CalHealthCares that incentivizes and supports that approach to delivering care.

Van: And what about the concept of value-based care?

Lupe: Currently, we’re excited to work with a number of small and medium-sized practices to support their work and their participation. An example is the most recent initiative by the Department of Healthcare Services around equity practice transformation. Our sweet spot is working with physicians and physician practices to advance community health and health equity.

Van: I’m looking forward to all that good work. Now, Lupe, as I previously mentioned, you hosted a Health Equity Leadership Summit. Tell us more about its purpose and share some of the content that was delivered.

Lupe: The Health Equity Leadership Summit was held in August of this year, the goal being to create a safe space, a collaborative space, a space of innovation and creativity and camaraderie for physicians, physicians-in-training, advocates and allies. We had a summit in which more than 100 individuals came to not only partake in creating that safe space, but really further discussing and having those conversations around how do we advance and champion health equity?

We kicked off our health equity summit with Dr. Pooja Mittal, who’s on the PHC Board of Directors. She’s also the HealthNet chief health equity officer, and she was joined by Reggie Tucker-Seely, who’s the vice president of health equity for ZERO Prostate Cancer. We had a number of different speakers really speak to an audience that wanted and needed a safe space  to discuss how do we do this? How do we do this together? What aren’t we doing? What could we do more of? And so the goal is not only to start the conversation, but to continue the conversation.

This is not new. Having conversations, having a community plaza where you can discourse and where you can provide information and strategize…none of those concepts are new. What makes our Health Equity Leadership Summit different though is this desire to move from conversation to action and to have a broad array of representation — not just from physicians and physicians-in-training — but advocates, allies, and others that are interested in advancing health equity.

Other sessions addressed the diversity, tax, moral injury, career satisfaction, how to show up as your authentic self, how to bridge those conversations with respect to identity, culture, values, patient health, et cetera.

One of my favorite parts of the summit was the “Walk With A Doc” which was held the second day in the morning. We had an opportunity to walk around San Jose, see some of the beautiful street art, see some of those murals and discuss the history. It really reinforced the concept of social determinants of health, which is this idea that where we live, where we work really impacts how we live, how our health shows up.

The Walk With A Doc was an important opportunity to step back and also say it’s not just how our patients show up in the physician practice offices and in the facilities, it’s also how do we advance care in those communities so that there’s a no wrong place approach.

Van: Well, thank you for your continued leadership on the equity front. Why don’t we wrap up by asking you for a sneak peek into your Physician Women of Color report that is going to be released soon. What are some major takeaways?

Lupe: We are excited to be able to release and share some of the outcomes from our Women Physicians of Color study. It is a renewed study. Our original research was done in 2018. It’s funded by the Physicians Foundation and it was an important opportunity to reflect on and really evaluate what was the experience of women physicians of color during the pandemic.

Walking into the pandemic, we knew that women physicians of color are already strained. They’re strained by external as well as organizational policies and practices. And what was interesting to see in the research is that we did see an increase in the number of women physicians in general and women physicians of color in terms of their increased burnout. It was also interesting to note that as we were doing some of the qualitative research with respect to focus groups, we also found that women physicians of color oftentimes have either immediate family and community interventions that help support and address their moral injury.

The purpose of the study was to acknowledge that more needs to be done at an organizational level, and more needs to be done at a policy level. Women physicians of color are such a key core component to how we deliver culturally dynamic quality care and we need women physicians of color to stay in their profession and continue to advance. While there are a lot of resilient factors that women physicians of color can experience, more still needs to be done in that space.

Van: Well, wonderful. We learned so much in our conversation with you today, Lupe. Thank you very much for being with us.

Lupe: It was an honor and just a wonderful opportunity to chat with you.  I look forward to more chats in the future.

Van: I’ll take you up on that. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.