IX. Physician Services

Information about physicians in practice in Imperial County has already been presented in Section IV, Health Manpower and includes numbers of physicians by specialty and the number of specialists who come to Imperial County on a part-time basis to provide care. These numbers suggest that there may be a shortage of physicians available in the county, which would infer that problems with access to care may also exist.

To gather further information on physician services and issues of access, a survey of Imperial County physicians was undertaken in February and March 1998. A model physician survey utilized by the DRIS project sites was reviewed and approved by the Imperial Valley Health Medical Staff Planning Group (consisting of hospital administrators and key physician leaders) and the Medical Executive Committees at El Centro Regional Medical Center and Pioneer’s Hospital. The survey was mailed in early February to all physicians with a cover letter from the Imperial Valley Health Care Advisory Council. Completed surveys were returned to UC Davis for compilation and to ensure confidentiality. A second survey was mailed two weeks later to non-respondents encouraging a response.

Physician surveys are often helpful in attempting to get as comprehensive a picture of medical practice as possible. However, a word of caution on interpretation of mailed surveys is in order. Data on hours worked and percentages of patients by payer source are usually reported as recall by the physician. Actual percentages of patients by payer sources and acceptance of new patients by category could not be verified. Overestimates of availability of new patient appointments may have occurred, based on the physician/population ratios reported earlier in this report.

A Note about the Charts: The Developing Rural Integrated Programs, funded by the James Irvine Foundation, is currently underway in five different locations in California. To allow comparison across sites, specific charts were developed for the display of data. However, due to local decisions, not all questions were included in the Imperial survey. Therefore, gaps in the table numbering are due to information not collected in Imperial.

Survey Findings

Table 9.1 provides an overview of the distribution of physicians in Imperial County by specialty. As reported earlier, there are 142 physicians in practice in Imperial County including 33 Primary Care Physicians (32.4 FTE), and 109 Specialists (78.05 FTE). Of the Specialists, 70 practice full-time in Imperial and 39 are "out-of-area" Specialists who come to Imperial County on a part-time basis (< 50% time) to see patients. This information was collected independently from the survey.

Source: Imperial County Medical Society, Pioneer Hospital, El Centro Regional Medical Center, AMA Directory of Physicians, 1996, CA Department of Consumer Affairs, and Yellow Pages

Table 9.1: Service Area Profile of Physician Specialties
Percentage of Total Primary Care 29.3% In Area Specialist 63.4% Out of Area Specialist 7.3%

The survey was sent to 134 physicians identified as being in practice in Imperial. (Initial findings of this survey lead us to do a more intensive review of this listing, resulting in the numbers described above. ) A total of 50 responses were returned for an overall response rate of 37%. This includes 15 from Primary Care Physicians (45% response rate), 28 from local specialists (40% response rate) and seven from out-of-area specialists (18% response rate). Table 9.2 summarizes the distribution by specialty of all the responses.

Source: Survey of Imperial County Physicians, Feb-Mar 1998

Table 9.2 Imperial County Responses by Specialty Catagory
Percentage of Total Primary Care 30.0% In Area Specialist 52.0% Out of Area Specialist 18.0%

Non-Respondent Bias: One of the limitations of a mailed survey is the fact that respondents who did not reply may in some manner be different than those who did. It is known that people who do not respond to surveys tend to be more neutral about the survey topic, resulting in a non-response. Thus, these individuals tend to be under represented in the survey results and represent potential "bias."

A response from nearly half the primary care physicians and 40 percent of the local specialists is considered reasonable for such a mailed survey. The consistency of responses to the survey questions was also strikingly similar. The responses from out-of-area physicians, at 18%, is considered low. However, it is important to remember that the 39 identified out-of-area specialists represent only 8.05 FTE or the equivalent of each spending one day a week in Imperial County. While they undoubtably offer valuable local access to more highly specialized care, their impact on overall access to care is less.

Physicians’ Schedules and Patient Volume: Tables 9.3, 9.4 and 9.5 present information on the amount of time physicians work each week and the number of patients seen in their offices. Physicians were asked to indicate if they worked less than 20 hours a week, between 20-40 hours a week or more than 40 hours a week. Primary care physicians had the largest percentage reporting working more than 40 hours a week (93%), followed by out-of-area specialists (87%) and then in-area specialists (82%).

In the Imperial survey, physicians were asked to estimate the average number of patients they see in their office during a typical week. It is felt that physicians’ estimates of the number of patients seen in an average week are more accurate than estimates of "annual visits." Thus, to estimate the "average annual visits" reported in the tables, a 48-week work year was used as the base. In addition, the median number of visits is provided. The use of the median provides the midpoint of number of office visits, with half the physicians seeing more than that number and half seeing less. As the use of an average can be weighted in one direction or another if some respondents see significantly more (or fewer) patients than most, the median is a useful "midpoint".

The primary care physicians in Imperial County see significantly more patients in their office each week than do specialists. The median number of office visits is 125 visits per week or 25 patient visits a day. This is not an unusual number of visits for a primary care physician. Specialists reported seeing a median of 52.5 patients a week in their office (the range was 0 - 170). It is difficult to comment on these numbers because so many different specialists are grouped together. The variation between specialities dictates that some specialists must spend significantly more time with a patient than do other specialists. The complexity of a patient’s illness may also require differing amounts of physician’s time. Finally, the question asked for office visits only, and many specialists spend a great deal of their time seeing patients who are hospitalized. Thus, no conclusion is reached concerning the number of office visits by specialists.

Payer Distribution: Physicians were asked to estimate what percentage of their patients paid for their services by various payer sources. Table 9.6 and 9.6.1 depict payer information for primary care physicians is broken down into two groups: Pediatricians and Family Physicians/General Practitioners/Internal Medicine. These groups were developed because pediatricians do not see Medicare patients and thus their distribution of payer sources is quite different. Each group represents approximately half of the primary care respondents to the survey. Pediatricians reported that 46% of their patients are covered by private insurance and 46% are covered by MediCal.

Source: Survey of Imperial County Physicians, Feb-Mar 1998

Note: "Other" includes Workers' Comp.

Table 9.6: Imperial County FP/GP/IM Payer Distribution
Percentage of Total Medi-Cal 29.4% Medicare 36.7% Traditional Indemnity 13.1% PPO/HMO 15.1% Self Pay 4.3% Other 1.4%

Source: Survey of Imperial County Physicians, Feb-Mar 1998

Note: "Other" includes Workers' Comp.

Table 9.6.1 Imperial County Pediatric Payer Distribution
Percentage of Total Medi-Cal 46.0% Medicare 0.0% Traditional Indemnity 25.0% PPO/HMO 21.0% Self Pay 8.0% Other 0.0%

Distribution of payer sources for Family Physicians/General Practitioners/Internists is similar to that reported by specialist physicians in Table 9.7. Approximately one-third of their patients are covered by Medicare and one-quarter are covered by MediCal. Another quarter are reimbursed by private insurance. The high percentage of patients covered by MediCal suggests that such patients do have access to Imperial physician’s services.

Source: Survey of Imperial County Physicians, Feb-Mar 1998

Note: "Other" includes Workers' Comp.

Table 9.7 Imperial County Specialist Payer Distribution
Percentage of Total Medi-Cal 25.4% Medicare 33.8% Traditional Indemnity 16.1% PPO/HMO 11.8% Self Pay 6.1% Other 6.8%

Physicians Accepting New Patients: Physicians were asked whether or not they were accepting new patients with various types of coverage. The results for primary care physicians is summarized in Table 9.8. Primary care physicians reported they were accepting all new patients with MediCal and Medicare coverage. All physicians reported accepting new patients who were self-pay. Eighty-five percent of specialists reported accepting new MediCal patients and 100% reported accepting new Medicare patients. Interestingly, only 80% of primary care physicians were accepting new patients with PPO or HMO coverage as were 88% of specialists. No information was gathered to explain this restriction.

Source: Survey of Imperial County Physicians, Feb-Mar, 1998

* Includes FP/GP/IM only

Table 9.8: Primary Care Physicians Accepting New Patients and Offering Sliding Scale Fees in Imperial County
New Patients 100.0% Medi-Cal 100.0% Medicare Assign* 100.0% Sliding Scale 54.0%

Physicians were also asked if they had offered a sliding scale schedule for self-pay patients. Fifty-four percent of primary care physicians indicated they offered such a scale and 69% of specialists offered such a scale. In general, most physicians did not report an established sliding scale schedule, but were willing to negotiate with a patient, taking into consideration a number of factors, including ability to pay (income) , size of family, local residency, amount of time spent with patient, etc.

Waiting Period to See Physician: Another potential indicator of problems with physician access is the length of time a patient has to wait between making an appointment with a physician and actually seeing the physician. Physicians were asked to report on waiting periods for established patients and new patients and between routine appointments and emergencies. This information is summarized in Table 9.9. Reported waiting times all appear to be quite short and reasonable. Nearly all physicians reported being able to see patients the same day if there was an urgent cause.

Conclusions

The responses to the questions asked in this survey present the following picture of Imperial County physicians:

• Most physicians appear to have full practices. While there may be individual physicians who are exceptionally busy, this does not appear to be the case universally.
• Physicians report seeing significant numbers of MediCal and Medicare patients. In addition, all primary care physician respondents indicated they are accepting new MediCal and Medicare patients to their practices.
• Waiting periods to see a physician are reasonable and not unduly long.
• The only indication of a potential barrier to care identified in the survey was that only half of primary care physicians offer a sliding scale schedule for patients with no insurance or limited ability to pay.
• When taken together, significant access barriers to physician services for Imperial County patients were not identified by this physician survey.

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