California is experiencing a physician shortage. Large numbers of physicians are retiring, and the growth in supply of new physicians is too slow to meet the demands of the ever-expanding population. In February 2019, the California Future Health Workforce Commission published a set of recommendations “to close the significant and growing gap between the health workforce that exists in California today and the one that will be required in the near future.” In particular, the commission focused on creative workforce solutions to remediate the shortages in primary care and mental health. One of the commission’s top 10 recommendations was to expand primary care and psychiatry residency programs to train sufficient numbers of these physicians to meet the needs of the people of California.

In response to the commission’s recommendation, the California Health Care Foundation convened a Graduate Medical Education (GME) Summit on October 23, 2019, in Oakland, California, to catalyze collective action on residency expansion in California. Participants were California GME experts from a variety of training hospitals and Teaching Health Centers representing different geographic regions, health systems, disciplines, and medical specialties. Representatives from Colorado, Georgia, and Texas also participated to discuss successful innovative GME expansion efforts in their states.

GME Summit participants reached consensus on the following points:

California should establish a GME Governance Council to expand graduate medical education to match the needs of California’s growing and diverse population, especially in geographically underserved areas of the state.

• As recommended by the Future Health Workforce Commission, the GME Governance Council would provide strategic planning, oversight, coordination, advocacy, guidance, and accountability for GME expansion statewide.
• The GME Governance Council should situate within the California state government to establish the legitimacy required for success, as well as strong standards for both accountability and transparency.The governor should appoint council leadership.
• The council should subcontract some portion of its work to a private entity.Such a public-private partnership allows for greater flexibility as GME priorities evolve over time and also allows for additional functions, such as GME advocacy at the federal level.
• An important focus of the GME Governance Council should be on GME expansion into Medicare GME-naive hospitals in order to maximize the infusion of federal Medicare GME funding into California.
• Examples of specific tasks of the GME Governance Council could include these:
  • Engaging with Medicare GME-naive hospitals to gauge interest in and promote GME
  • Making small grants to hospitals and community health centers to conduct GME feasibility studies
  • Making short-term grants to cover start-up costs for new programs
  • Providing technical assistance (e.g., toolkits, white papers, consulting) to hospitals and community health centers to assist with GME expansion
  • Coordinating GME expansion efforts across California, particularly with the Song-Brown program, CalMedForce, and the Workforce Education and Training program

The California Department of Health Care Services should include a Medi-Cal GME expansion program in the 2020 Medicaid CalAim Initiative.

• This requires immediate action, as the proposal is currently under development and will be submitted to the Centers for Medicare & Medicaid Services (CMS) in spring 2020.
• New federal matching funds should be explicitly targeted to new residency positions in safety-net health care organizations (e.g., community health centers, public hospitals, rural hospitals) that disproportionately serve Medi-Cal members and other underserved populations.

Next Steps

The participants of the GME Summit agreed that collective action is required to improve health care access in California by expanding the physician supply to meet the demands of California’s growing and increasingly diverse population. Evidence indicates that where physicians complete their residency or fellowship training is the strongest predictor of where they will practice medicine. Several concrete next steps were identified for encouraging GME expansion in both hospitals and community health centers, and include actions such as conducting case studies to determine best practices when launching a new program and encouraging the California Legislative Analyst’s Office to study the creation of a governance council within the state government. The California Health Care Foundation is committed to continued support of GME expansion planning efforts, including identifying potential philanthropic funding partners for long-term funding. Likewise, other summit participants agreed to work together to increase awareness and to achieve these common goals.