Ko Examines Healthcare in the San Joaquin Valley

By M. Rossi – Why is a certain part of the Central Valley often referred to as “the Appalachia of the West?” On April 6, 2018, in a talk titled “Scarcity in the Land of Plenty: Healthcare in California’s San Joaquin Valley,” Assistant Professor of Public Health Sciences Michelle Ko explained.

An affiliate of the Center for Poverty Research and the Center for Healthcare Policy and Research, as well as a co-leader of the Community Outreach and Engagement Core of the UC Davis Environmental Health Science Center, Ko focuses on the intersection of policy, healthcare, and social structures, particularly with regard to marginalized communities. She has conducted research ranging from the healthcare safety net and Medicaid to long-term care and access for minority populations. She is also interested in diversity in medical education and the healthcare workforce.  

Ko began her talk by defining health-services research as “a science of study that determines what works, for whom, at what cost, and under what circumstances.” She also highlighted the multi-disciplinary nature of the work, which draws on theory and research from economics, sociology, epidemiology, psychology, anthropology, public policy, political science, and the health professions. 

Chronic conditions, social structures

Nestled between the 5 and the 99, the Central Valley is the agricultural heartland of California. Comprised of eight counties and four million people, and ranging from rural to metropolitan, it is afflicted with both structural inequalities and high rates of poverty. The San Joaquin Valley is rife with chronic conditions (such as obesity, food insecurity, and diabetes), occupational health injuries, pesticide exposure, and mental health problems. These health risks compound and intersect with social structures that determine disparate health outcomes.

Healthcare in the valley suffers from a low primary care physician supply, with most areas reporting only 17-39 primary care physicians per 100,000 residents in 2015. According to Ko, that’s “less than half the per capita of the Bay area.” To make matters worse, the region’s older, whiter, and more male physician supply suffers from concerns about retirements and underrepresentation of female medical school graduates. Plus, nearly half of the physicians are international medical graduates, a fact that has clear implications in terms of immigration policies. The burning question, then, is: how to fill the shortages?

Challenges, experiences, and issues 

In this study, Ko sought to describe the experiences and perspectives of primary care providers and community clinic physicians. Implementing a qualitative method, she has thus far interviewed 16 physicians and clinic directors. Seven of these are female, and five are Latino—an unusually representative subsample. 

Ko shared the preliminary themes that have emerged. To begin, she explicated such systemic challenges to healthcare practice as a shortage of physicians leading to inability to obtain specialist care, a lack of specialty competition leading to low quality of care, and high volume of patients to serve, with no back-up. Other challenges include low Medi-Cal reimbursement, lack of transportation, and the negative impact of non-supportive administrators.

Meanwhile, women and those from the LGBT community report that negative professional experiences push out those who do choose to practice in the underserved region. Ko admitted that she didn’t start the study with these barriers in mind, but that talking to women during time the #MeToo movement has illuminated the realities. 

Other contemporary issues—immigration enforcement concerns, heightened mental health awareness, uncertainty in healthcare policy and insurance enrollment, and environmental conditions—exacerbate these challenges. As such, the cumulative impact of these problems creates further recruitment and retention challenges. With differential responses by gender, females are concerned with a lack of potential partners, of job opportunities for partners, and of minimal cultural amenities.

Reflections, next steps, and emerging questions

Ko acknowledged the mismatch between challenges and proposed solutions regarding physician supply and between the regional and professional culture. She advocated for a focus on both the educational pipeline (inclusive of K-12) and training infrastructure. Next, she plans to continue data collection, with a target of 30 interviews in sight, and will then implement the quantitative component of the project. 

Ko’s preliminary research, coupled with the evolving policy context, has already generated new research topics and projects. These include harassment, discrimination, and immigration policy effects on the supply of physicians; predictors of entry/exit over time using longitudinal Medical Board data; and understanding experiences of other providers such as Doctors of Osteopathy, Nurse Practitioners, and Physician Assistants.

While findings from this study may be a bitter pill to swallow, their translation into effective policy that ameliorates the shortages and disparities may be just what the doctor ordered.  

Learn more about Michelle Ko.