Sacramento simply refuses to live up to Americans’ preconceived notions of California. It has no long, sandy beaches covered with tanned bikini-clad babes. Residents here will never celebrate a Super Bowl ring or World Series championship. The housing costs aren’t rising through the roof. And the state’s capital city lacks an abundance of doctors.
Gregory Cooper, DPM, found Sacramento to be a satisfying landing point. He grew up in San Diego, practicing at the Scripps Clinic there for 15 years and rising to the medical director’s position before scrapping it all to work in Champaign, Illinois. But his wife, a Southern California girl at heart, couldn’t make the adjustment, so the Coopers headed back to the Golden State looking for some kind of compromise.
"A Midwest town offers a slower pace of life and people are friendlier. I found that in Sacramento," says Cooper, now the chief medical officer over 120 physicians at the MedClinic Medical Group, a multi-specialty group operated by Catholic Healthcare West.
Yet Sacramento is unlike the typical Midwest city in that Time magazine named it the most diverse city in the nation in 2002. Time reports 41 percent of the residents are non-Hispanic white, 15.5 percent are black, 22 percent Hispanic, and 17.5 percent Asian/Pacific Islander. Kieran Fitzpatrick MD, the chief of the Kaiser Permanente Medical Group at the South Sacramento facility, sees similar breakdowns in his patient mix. "It means if you come to Sacramento fluent in a second language, it’s a real advantage," he notes.
For newcomers like Susan Wadhwani, who recently joined Sutter Health as the director of physician recruitment for the Sacramento Sierra Region, it means she can shop the English specialty shop a few blocks from her house for nearly anything she’d find in her native England. "And you want to talk about eating? Just around the corner, they’ve opened an Ethiopian restaurant," she brags. "Turkish, Moroccan, Indian, Vietnamese, Thai, Chinese, French - you’ll find some very nice surprises."
"Within California, there’s sometimes an attitude that Sacramento is a farm community just because it is in the valley. After moving here a few years ago, I found nothing could be further from the truth, especially with all the excitement the state politics bring to the table," admits Mary Beth TeSelle, a communications expert with Catholic West.
Westerners officially label Sacramento the City of Trees. But that was too narrow a description for cardiologist R.J. Frink, MD when he moved to the city in 1963 to raise his four children - he dubbed it "the undiscovered garden spot of the world."
The NBA’s Sacramento Kings may be the only professional sports game in town, but residents barely take time to notice the missing NFL or Major League Baseball teams between their own biking, running, and Class IV river rafting. Kids sign up for organized soccer and baseball leagues in droves. The valley’s warm climate encourages swimmers; residents are proud to note famous athletes like Mark Spitz come from Sacramento.
"And it’s an easy day trip to go skiing in the Sierras or Tahoe from here," Fitzpatrick says. Indeed, while the city basked in 80 degrees last May, the mountains saw a two-foot dump of snow and kept the ski lifts open through Memorial Day. Those who prefer a Napa Valley wine tasting tour can take I-80 directly to the Bay. Amtrak operates between 12 and 14 trains daily between downtown Sacramento and San Francisco to handle commuter needs.
Meanwhile, Silicon Valley giants like Intel, Compaq, and Hewlett-Packard have begun building subsidiary facilities in the area to capture more of the high intellectual community as its worker base. City planning officials welcome the high tech influx to join the stable base of state government jobs that anchor Sacramento’s economy.
It’s also fueling development for the city and surrounding towns. Although the population of Sacramento proper is a mere 400,000, the service area covers more than two million citizens. What was once farmland quickly is converting to housing developments at prices below other California metropolises - as much as 30 to 50 percent less than their Bay Area counterparts. "So you have an expansion in the housing market because people can afford it. They buy into the lower end housing and then move up," says Cooper. Consequently, many homes have appreciated 20 percent in value in recent years.
"I’m sure you can find cheaper places to live in the West, but if you want to live in California, this is the most affordable place to be," Fitzpatrick says.
Overall, greater Sacramento’s population is growing at about five percent annually, with Oak Grove, Folsom, Roseville, and San Tomas registering the biggest booms - the latter currently experiencing an unbelievable 75 percent annual growth rate. Families naturally are a big part of that growth, forcing the school systems to constantly build new facilities to handle the student populations. Auburn, to the south, has three schools a year on the drawing board for the foreseeable future.
Cooper sees another ramification. "The hospitals are seeing a significant portion of the physicians reaching out to these growing communities, and we’re having to fill the holes this leaves in the city area."
Sacramento’s slew of hospitals definitely raises the quality of medicine in the Valley - in more ways than just counting high tech machines at each building. With four major systems clustered several miles apart, physicians realistically interview with more than one set of recruiters when they roll into town. "I’m of the philosophy we need to make the visit as congenial as possible for the candidate, and if that includes my competitive colleagues, so be it," says Sutter’s Wadhwani. "I’ll cooperate with them because it only makes sense to split the costs of that candidate’s trip. The outcome should be that doctors come to Sacramento, period."
That practicality reflects why the VHA Health Foundation chose Sacramento as one of three key cities to demonstrate that community healthcare organizations can work together to employ desperately needed healthcare workers. The program, called Community-Wide Career Ladders, involves the design and development of local programs that target the unemployed and current health-care workers by giving them opportunities to advance in the health-care sector.
Kaiser Permanente owns three hospitals in the area that take care of approximately 600,000 members annually. Sutter Health maintains two facilities, Catholic Health Care West operates three, and the University of California-Davis medical center lends a heavyweight aura to the entire hub. "UCD definitely raises the level of care in this community," Frink says succinctly. "And they have become a major force by attracting many private patients." The Shriners, too, picked Sacramento to locate one of their renowned children’s hospitals. Fitzpatrick estimates as many as four million people a year are referred into Sacramento.
So it’s no surprise that administrators constantly scramble to have their facilities be the first with new instruments, procedures, and ideas. For instance, Sutter Health invested $25 million in a remote high tech surveillance system known as an electronic intensive care unit (eICU) to fill the role of a hospital intensivist. "Studies show that round-the-clock intensive coverage in the ICU is key to better patient outcomes. But there are only 6,000 intensivists practicing in the U.S., which means only 40 percent of all ICU patients get this kind of attention," says Wadhwani. Now the advanced video and electronic monitoring connects off-site critical care specialists to multiple ICUs. Sutter is the first site on the West Coast to introduce the concept. Only Chicago has seen this technology in the entire country.
Competition also means taking chances, like the Midtown Sutter District under construction to open in late 2008. It will contain an eight-story, 200-bed Women’s and Children’s Hospital, a 315-bed Sutter General, a $35 million live theater complex, 32 housing units, and a shopping/restaurant section. Sutter Health Sacramento is spending $385 million in an effort to incorporate the arts into the healing process.
While these four systems don’t employ physicians per se, they do support and control a large group of local physicians through ownership of the physician groups, Frink reports. Wadhwani confirms the idea of having privileges at more than one hospital isn’t the norm; private practice opportunities are drying up quickly. Frink owns a small medical building across from Mercy Hospital and had to rent the space to dentists even though it was equipped for physicians. "When a doctor comes to town, he joins a Kaiser," he says.
If there is one thing everyone in Sacramento agrees on, it’s the need for changes in the health-care payment system. "Affordable health care is a message everyone is hearing from constituents," California State Senator Dario Frommer told the Sacramento Bee in August. The Democratic Senator from Los Angeles, who is chairman of the Assembly Health Committee, continued, "Employers talk about premiums, workers talk about how much they pay, hospitals talk about how little they get paid, HMOs talk about how much hospitals charge. It becomes quite a cacophony of complaint."
Welcome to California, where the medical community is always buzzing with news of this bill or that brewing in the capital city. In 2003 alone, state legislators contemplated at least four health care bills: A "pay or pay" law that would mandate HMO benefits with prescription drug coverage for all workers - even part-time and seasonal hires; a cap on how much hospitals could charge the poorest uninsured patients; fines for violating the state’s new nurse staffing law that took effect January 1; and a mandate that would force hospitals to reveal their sticker prices publicly.
With managed care penetration hovering near 90 percent of all insured patients, Sacramento also carries the dubious honor of being the managed care capital of the United States. "Which means we’ve been through the bloodiest of the battles and have outgrown where other parts of the state and country are still engaged," points out William Sandberg, the executive director of the Sierra Sacramento Valley Medical Society.
But physicians do have a few white knights on their side. Private healthcare foundations established the country’s first HMO hotline in Sacramento back in July 1996, known as the Health Rights Hotline. It’s an effective model to help health-plan enrollees resolve difficulties with their plans. Currently, 87 percent of callers rate this organization’s intervention as "useful."
Patients can also rely on the efforts of the HMO Help Center, operated by the California Department of Managed Health Care (DMHC), and often referred to as a "control tower over the HMO industry." The DMHC offers more than just problem-solving negotiators - its legal teeth have levied more than $1.5 million in fines against state HMOs who violate the law since it opened its doors on July 1, 2000. But the patient population best knows the DMHC for its annual HMO report card, scoring each group’s effectiveness based on information from patient medical charts and service records.
The most recent results for Sacramento area HMOs show time doctors spend with patients is good across the board (scores of 79 to 87 out of 100) as is the fact that doctors listen carefully (83 to 91). The percentage of HMO members who received beta blocker drugs after a heart attack looks very impressive: a low of 89 percent at Aetna Health of California to a high of 97 percent for Health Net. However, when it comes to issues like how well the HMOs properly control blood sugar levels in diabetic patients, the scores range from a low of 62 for Aetna Health of California to a high of 70 for Health Net. Controlling cholesterol for diabetic patients is even more dismal: a low 52 for CIGNA HealthCare to high 63 for Kaiser Permanente-North.
The overall atmosphere with managed care is changing for the better, in Cooper’s estimation. After 20 years wrestling with various versions, he now just shrugs and hires office staff to handle the necessary paperwork. "There are some good aspects," he adds. "The focus of managed care is to keep the patient healthy, so a lot of preventative care takes place in our medical groups. Then when you need the appropriate treatment or surgery, you will get it."
Of course, managed care isn’t the only California phenomenon in the headlines. The new governor, Arnold Schwarzenegger, made the state’s economic condition a national concern, and his high-powered profile continues to keep the topic in the forefront. But it doesn’t concern Fitzpatrick. "It’s a cycle," he says firmly. "Every part of the country has been through certain economic downturns. We went through a big one in the early ’90s when they closed a lot of military bases and unemployment shot to something like nine percent. By the mid- to late ’90s, it was back around three percent.
"California is a state that draws people who want to do new things, and I’m sure we’ll be leading the nation in many areas soon, just like we have in the past," he says.
That time is still now for the Sierra Sacramento Valley Medical Society. It was the first medical society in the state, incorporated in 1868, and can boast establishing the University of California Davis Medical School. Today more than 250 of the total 2,000 members are involved in the society’s committees and delegations, sponsoring important position papers like a landmark study on the undertreatment of chronic pain, which lead to successful state legislation. Thank the SSVMS for establishing Sacramento’s only Fortune 500 company when it started Foundation Health, now absorbed by Health Net. Current projects on the table include an effort to convert the city’s coroner’s office to a medical examiner’s
Perhaps the most talked-about report in recent times is the physician supply study the society released in January 2001. During five years under the microscope, Sacramento’s total number of active physicians declined by 11.7 percent while the population increased by 9.6 percent. More than a third of the total loss drained from family practice, general practice, internal medicine, ob/gyn, and pediatrics. Diagnostic radiology, psychiatry, emergency medicine, ophthalmology, and general surgery also took measurable hits. The society’s internal data showed that 154 members retired during the five years while 116 left the area to practice elsewhere. "We would expect that these two numbers would likely double if we had the comparable information on non-members," says SSVMS executive director Sandberg.
The trend doesn’t seem to have abated since the report was published three years ago. The University of California Davis Medical School graduates roughly 100 physicians each spring, and even if all of them remained in the area it wouldn’t be enough to meet Sacramento’s exploding population demands, says Fitzpatrick. "Kaiser alone hired 100 doctors last year, so the community as a whole probably needed close to 300," he estimates. Corporate lay-offs still looming from the state’s hard-hit economy could slow things down for a few years, but even that prediction is a crap shoot. The next healthcare legislation could generate more insurance coverage and more work.
Cooper is actively seeking specialists in dermatology, orthopedics, cardiology, interventional radiology, and anesthesiology for MedClinic Medical Group. Primary care is perpetually on Wadhwani’s list, even though Sutter absorbs 80 percent of the participants in its family practice residency program annually. Fitzpatrick says he recruited for every specialty in 2003. "There isn’t an oversupply of any specialty in Sacramento," he notes. What’s more, the patient base is all but assured.
"We don’t put a search out there unless we have a community need," Wadhwani says. "The last thing you need is to bring in a physician that doesn’t have enough patients. That’s death to you as an institution and it makes a physician very unhappy. When someone’s appointment books are filled three months in advance and this has gone on for a year, that’s a good sign you need more physicians in that specialty. So we do our homework before we advertise any opening."
A majority of candidates spill out of the Bay Area or are Southern California physicians who hate the morning commutes. But that’s not to say medical students from the Midwest and East Coast won’t consider Sacramento. Officials typically benchmark salaries according to the American Medical Association’s annual survey of major medical groups in the United States - and Sacramento’s shortage means groups pay more here than in other parts of the state. "Obviously the reality is that if you’re working in a non-managed care environment in the middle of the country, you will make a little more money than you can in California," Cooper admits, "but not that much more.
"Sure, I want to put away a bit of money, but at the end of the day I’m happier if I can get out in the middle of January and go for a 50-mile bike ride and run every day…see the sun," he adds.
Medical groups and the SSVMS place a higher value on such mental well-being. Last decade the society studied 35 percent of its members in Sacramento and El Dorado counties to probe burnout levels. The results revealed middle-of-the-road numbers to questions like "to what degree do you consider yourself experiencing burnout?" "To what degree is your experience of burnout greater now than it was three years ago?" and "To what degree do you think physician burnout poses a current problem to your medical group or practice?" Not surprisingly the top six stressors physicians in this county identified were:
• autonomy/managed care
• ability to impact work environment
• long hours
• control over own time
• juggling personal and professional life
In the "other" blank, they wrote in stressors like financial concerns, career uncertainty, and paperwork. But these are not problems unique to Sacramento.
"I spoke to a young physician yesterday who needed a life change," Wadhwani shares. "She said, ’It’s time to move on and I’ve decided Sacramento is where I want to be.’
"When I came here I thought it might be a hard sell because we are competing with San Francisco, Oakland, and Berkeley. I haven’t found that to be the situation at all," Wadhwani says. An ideal California lifestyle without the high cost - who wouldn’t consider it? �
Julie Sturgeon is a freelance writer in Greenwood, Indiana. She regularly contributes to Unique Opportunities.