California Physicians: Surplus or Scarcity? March 2014

Transcription

1 : Surplus or Scarcity? March 2014

2 Introduction The number of physicians in California has grown steadily over the past 20 years, increasing 39% from 1993 to 2011, and outpacing the state s 20% growth rate in the general population. Demand for physician services is expected to increase with the aging of the state s population and the implementation of the Affordable Care Act. Ensuring access to care is also a concern, as close to one-third of California s physicians are near retirement age. : Surplus or Scarcity? describes the current market landscape for physician services in California. Key findings include: Physician supply varied by region. The number of physicians in the Inland Empire and San Joaquin Valley fell below the recommended supply of primary care providers and specialists. The total number of physicians in California did not accurately reflect their availability to provide care. About 20% of all physicians devoted less than 20 hours a week to patient care. Slightly more than 30% of California physicians were over the age of 60 only New Mexico had a larger proportion of physicians in this age group. Latinos were underrepresented among physicians. While 38% of the state s population was Latino, only 4% of physicians were Latinos. contents Supply Hours Worked Demographics Practice Organization Education and Training Income Medical Groups Quality of Care Health Care Reform Data Resources Appendices More than three-quarters of California physicians attended medical school in other states or in foreign countries. Physicians were less likely to serve Medi-Cal, Medicare, and uninsured patients in their practices than privately insured patients California HealthCare Foundation 2

3 Active Physician Trend California, 1993 to 2011 number of physicians 100,000 90,000 91,775 Supply The number of active physicians practicing in California has grown steadily, increasing 39% from 1993 to In comparison, 80,000 70,000 60,000 66,151 the state s general population grew by just 20%. 50,000 40,000 30,000 20,000 10, Note: Data include active MDs and exclude residents, fellows, and MDs who are retired, semi-retired, working part-time, temporarily not in practice, or not active for other reasons and who indicated they worked 20 hours or less per week. Source: American Medical Association, Division of Survey and Data Resources, Physician Characteristics and Distribution in the U.S., 1993, 1994, , , , 1999, , , , , 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, California HealthCare Foundation 3

4 Supply of Select Providers California, 2004 and 2013 Supply From 2004 to 2013, the supply of MDs RN-Nurse Practitioners Physician Assistants 11,203 4,924 8, % 16, % 82, , % physicians, physician assistants, and advanced practice nurses grew significantly. Doctors of Osteopathy (DOs) and RN clinical specialists experienced the DOs 2,658 5, % greatest percentage growth over the period, while MDs and nurse RN-Clinical Specialists 1,813 3, % RN-Anesthetists 1,134 1, % practitioners experienced the largest absolute growth. RN-Midwives 995 1, % Notes: Includes all active providers with a California address. The Agency for Healthcare Research and Quality has estimated that 53% of nurse practitioners and 43% of physician assistants are primary care practitioners. See The Number of Nurse Practitioners and Physician Assistants Practicing Primary Care in the United States: Primary Care Workforce Facts and Stats No. 2, October 2011, Agency for Healthcare Research and Quality, Source: California Department of Consumer Affairs, 2013; special request, private tablulation California HealthCare Foundation 4

5 Health Care Providers, by Type and Region California, 2013 Central Coast (n=6,995) Greater Bay Area (n=35,666) Inland Empire (n=10,221) Los Angeles County (n=36,276) Northern and Sierra (n=4,172) Orange County (n=11,508) MDs DOs Nurse Practitioners Physician Assistants 76% 4% 13% 8% 81% 12% 4% 2% 70% 8% 12% 10% 81% 10% 5% 3% 67% 5% 17% 10% 76% 5% 12% 7% Supply Medical care can be obtained from health care providers other than physicians. In the Inland Empire, San Joaquin Valley, and Northern and Sierra regions, physicians (all active MDs and DOs) made up less than 80% of health care providers. Sacramento Area (n=8,193) San Diego Area (n=13,134) San Joaquin Valley (n=9,111) California (n=135,276) 78% 4% 12% 6% 78% 4% 13% 6% 72% 5% 15% 9% 78% 4% 12% 6% Notes: Includes all active providers with a California address. Segments may not add to 100% due to rounding. See Appendix A for a list of counties within each region. Source: California Department of Consumer Affairs, 2013; private tablulation California HealthCare Foundation 5

6 Estimating the Number of Active Patient Care Physicians California, 2013 All Active MDs ,770 Residents/ Fellows 7,013 Nonrespondents 11,526 EXCLUDING No Patient Care 3,522 Patient Care <20 Hours 12,171 Active Patient Care MDs 71,538 Supply Counting physicians in California is not clear-cut. The number varies based on how physician is defined. The broad category of active physicians includes a number of physicians who would not be considered active patient care physicians, including residents, fellows, nonrespondents, and MDs who devote less than 20 hours per week to patient care Notes: The Medical Board of California (MBC) surveys MDs when they obtain or renew their licenses. Nonrespondents include MDs who did not complete the survey and those who opted to make their response private. Sources: Medical Board of California, Survey of Licensees, May 2013; private tabulation. California Department of Consumer Affairs, 2013; special request; private tablulation California HealthCare Foundation 6

7 Primary Care Physicians and Specialists California vs. United States, 2011 Supply California and the nation had number per 100,000 Population PCPs Specialists similar per capita ratios of primary care physicians (PCPs) and specialists, according to RECOMMENDED SPECIALIST SUPPLY }(85 105)* RECOMMENDED PCP SUPPLY }(60 80)* data collected by the American Medical Association (AMA). However, the state barely met the 64 nationally recognized standard for supply of PCPs, based on data collected by the Medical Board of California (MBC). AMA Data, US AMA Data, California MBC Data *The Council on Graduate Medical Education (COGME), part of the US Department of Health and Human Services, studies physician workforce trends and needs. COGME ratios include DOs and are shown as ranges in the chart above. Notes: Includes only MDs involved in patient care, excluding residents and fellows. The two sources have differing methodologies for identifying primary care, resulting in proportionally more specialists in the MBC data. Sources: AMA, Division of Survey and Data Resources, Physician Characteristics and Distribution in the U.S., 2013 Edition, Tables 1.9 and 3.7. Coffman J.M., Traister L., tabulation of responses to the 2011 supplement to the Medical Board of California (MBC) mandatory survey of physicians, US Census Bureau, Population Division; Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States and States: April 1, 2010 to July 1, 2012; June California HealthCare Foundation 7

8 Primary Care Physicians and Specialists by Region, California, 2011 number per 100,000 Population Inland Empire San Joaquin Valley Northern and Sierra Central Coast Los Angeles County San Diego Area Sacramento Area Orange County Greater Bay Area California RECOMMENDED PCP SUPPLY (60 80)* RECOMMENDED SPECIALIST SUPPLY (85 105)* PCPs Specialists 175 Supply Physician supply varied by region. The San Joaquin Valley and the Inland Empire both fell well short of the recommended supply of primary care physicians (PCPs), and were the only areas that did not meet the recommended supply of specialists. *The Council on Graduate Medical Education (COGME), part of the US Department of Health and Human Services, studies physician workforce trends and needs. COGME ratios include DOs and are shown as ranges in the chart above. Notes: Data include active MDs working 20 or more hours in patient care per week, excluding residents and fellows. See Appendix A for a list of counties within each region. Source: Coffman J.M., Traister L., tabulation of responses to the 2011 supplement to the Medical Board of California s mandatory survey of physicians, California HealthCare Foundation 8

9 Top Ten Specialties California, 2013 number of active patient care physicians Family Medicine 7,740 Supply The three largest specialties in California were primary care Internal Medicine Pediatrics Psychiatry and Neurology-Psychiatry 5,310 4,789 7,140 specialties. Family medicine and internal medicine together represented one-fifth of all active patient care physicians Anesthesiology 4,442 in the state. Obstetrics/Gynecology 3,884 Emergency Medicine 3,606 Radiology Internal Medicine- Cardiovascular Disease Orthopedic Surgery 2,246 2,225 2,787 Notes: Data include active MDs working 20 or more hours in patient care per week, excluding residents, fellows, and nonresponders (i.e., those MDs who did not respond to the survey or opted to make their response private); 11% were nonresponders. Physicians whose primary specialty was internal medicine and who listed a secondary specialty (e.g., cardiology) were assigned to the secondary specialty. Similarly, pediatricians with a subspecialty were assigned to the secondary specialty. 1,425 doctors (1.5%) remained with no specialty assigned. Source: Medical Board of California, Survey of Licensees, May 2013; private tabulation California HealthCare Foundation 9

10 Patient Care Hours Worked California, 2013 average weekly hours 1 to 9 7% 10 to 19 7% 20 to 29 12% 0 4% 40 or more 49% Hours Worked The total number of physicians does not accurately reflect the availability of physicians to provide care. About half of California physicians devoted 40 hours or more a week to patient care. Physicians also spent time on research, teaching, and administration. 30 to 39 21% Note: Data include active MDs, excluding residents, fellows, and nonresponders (i.e., those MDs who did not respond to the survey or opted to make their response private); 11% were nonresponders. Source: Medical Board of California, Survey of Licensees, May 2013; private tabulation California HealthCare Foundation 10

11 Physician Hours Worked, by Activity California, 2009 and 2013 Hours Worked The average physician s workweek average weekly hours Administration/Other Research/Teaching Patient Care increased by over two hours from 2009 to 2013, driven by a rise in activities other than patient care Note: Data include active MDs, excluding residents, fellows, and nonresponders (i.e., those MDs who did not respond to the survey or opted to make their response private); 11% were nonresponders. Source: Medical Board of California, Survey of Licensees, May 2013; private tabulation California HealthCare Foundation 11

12 Physician Hours Worked, by Activity and Years Since Graduation California, 2013 Hours Worked Later in their careers, physicians average weekly hours Administration/Other Research/Teaching Patient Care tended to work fewer hours a week in all areas, with the largest decline in patient care hours Overall YEARS SINCE MEDICAL SCHOOL GRADUATION Note: Data include active MDs, excluding residents, fellows, and nonresponders (i.e., those MDs who did not respond to the survey or opted to make their response private); 11% were nonresponders. Source: Medical Board of California, Survey of Licensees, May 2013; private tabulation California HealthCare Foundation 12

13 Age of Physicians Select States vs. United States, 2012 percentage of total Physicians Under to 60 Over 60 Demographics The California physician workforce was one of the oldest in the nation; only New Mexico (not California New York Florida United States 16% 52% 32% 18% 52% 30% 13% 57% 29% 17% 55% 28% shown) had a greater proportion of active physicans older than 60. Slightly more than 30% of physicians in California were over 60. Illinois 20% 54% 26% Texas 19% 56% 25% Notes: Data include all active MDs and DOs. Segments may not add to 100% due to rounding. The five most populous states are shown. Source: Association of American Medical Colleges, 2013 State Physician Workforce Data Book, Table California HealthCare Foundation 13

14 Gender of Medical School Graduates and Physicians California vs. United States, 2012 Demographics The gender split among California Medical School Graduates California Active Physicians California medical school graduates was about even. Males, however, still represented the majority 48% US 52% 32% US 68% of physicians, due largely to a large gender gap in medical Female 48% Male 52% Female 34% Male 67% school graduates in the past. The female proportion of graduates has grown significantly from 9% in 1966 (not shown) to 48% in Notes: Data include active MDs and DOs. Segments may not add to 100% due to rounding. Source: Association of American Medical Colleges, 2013 State Physician Workforce Data Book, Table 27: Total Graduates by U.S. Medical School and Sex, , California HealthCare Foundation 14

15 Race/Ethnicity of Physicians and Population California, 2012 Latino African American No Response 13% Other 7% 3% 4% Asian 21% Active Physicians White 52% Latino 38% California Population 6% 3% African American Other Asian 13% White 39% Demographics The racial/ethnic breakdown of California physicians was not representative of the state s diverse population. In particular, California s Latino population was significantly underrepresented in the physician population: 38% of the population was Latino, while only 4% of physicians were Latino. Notes: Data include active MDs. Other includes American Indian/Native American/Alaskan Native, Native Hawaiian, and respondents who chose two or more races/ethnicities. Segments may not add to 100% due to rounding. Source: Medical Board of California, Cultural Background Survey Statistics, 2012; US Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States and States: April 1, 2010 to July 1, 2012; June California HealthCare Foundation 15

16 Latino Physicians and Population, by Region California, 2012 Northern and Sierra 2% 17% Greater Bay Area Sacramento Area Orange County Central Coast Inland Empire Los Angeles County San Diego Area San Joaquin Valley 2% 3% 4% 4% 4% 4% 5% 5% 21% 24% Latino Physicians Latino Population 34% 36% 42% 47% 49% 49% Demographics Latinos were underrepresented in the physician population in all regions of California. This underrepresentation was particularly pronounced in the Inland Empire, Los Angeles, and San Joaquin Valley. CA AVERAGE (4%) CA AVERAGE (38%) Notes: Data include active MDs. See Appendix A for a list of counties within each region. Source: Medical Board of California, Cultural Background Survey Statistics, 2012; US Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States and States: April 1, 2010 to July 1, 2012, June California HealthCare Foundation 16

17 Spanish-Speaking Physicians, by Region California, 2007 and 2012 Sacramento Area Greater Bay Area Northern and Sierra Inland Empire San Joaquin Valley Orange County San Diego Area Central Coast Los Angeles County 10% 10% 13% 14% 14% 14% 15% 16% 16% 17% 17% 17% 18% 19% 19% % 22% 23% Primarily Spanish-Speaking Population 5% 8% 5% 14% 16% 13% 12% 16% 19% Demographics The proportion of physicians that speak Spanish increased slightly from 16% in 2007 to 18% in Six of the nine regions in California had over 10% of their population primarily speaking Spanish. CA AVERAGE: 16% 18% Notes: Data include active MDs. Primarily Spanish-Speaking Population includes all people 5 years old and older who are Spanish speakers and speak English Less than Very Well. See Appendix A for a list of counties within each region. Sources: Medical Board of California, 2007 and 2012 Foreign Language Survey Statistics; US Census Bureau, American Community Survey 5-Year Estimates, Table S1601: Language Spoken at Home, and California HealthCare Foundation 17

18 Physicians, by Practice Setting and Region California, 2011 Central Coast 27% 38% 35% Greater Bay Area Inland Empire Los Angeles County Northern and Sierra Solo Practice Group Practice Kaiser Permanente Other 15% 34% 29% 22% 19% 37% 18% 27% 26% 37% 14% 24% 26% 36% 38% Practice Organization In all California regions, group practices were the most common setting in which physicians worked. Kaiser, the largest group practice in the state, had a significant presence in the Bay Area and Sacramento regions. Orange County Sacramento Area San Diego Area San Joaquin Valley California 27% 41% 13% 18% 9% 39% 27% 25% 16% 45% 9% 31% 22% 33% 15% 30% 21% 37% 17% 25% Notes: Data include active MDs working 20 or more hours in patient care per week, excluding residents and fellows. Point estimates should be interpreted with caution because the confidence intervals around them are large. Percentages are of physicians who reported a practice type. Across the nine regions, 5% to 11% of active patient care physicians did not respond to the question about practice type. Group practice encompasses all physicians in practices with two or more MDs other than the Permanente Medical Group. Other includes community clinics, public clinics, rural clinics, military facilities, VA medical centers, and other settings. In the Central Coast and Northern/Sierra regions, physicians who practiced in Kaiser Permanente facilities were combined with Other physicians due to small numbers of observations. Segments may not add to 100% due to rounding. See Appendix A for a list of counties within each region. Source: Coffman J.M., Traister L., tabulation of responses to the 2011 supplement to the Medical Board of California s mandatory survey of physicians, California HealthCare Foundation 18

19 Physicians with Patients in Practice, by Coverage Type California, % 69% 88% All Physicians Medi-Cal Medicare Private Insurance Uninsured 62% 59% 60% 61% 56% PCPs 89% 73% 87% Specialists Notes: Data include active MDs working 20 or more hours in patient care per week, excluding residents and fellows. If a physician reported that they had any patients in a payer category, they were included. Source: Coffman J.M., Traister L., tabulation of responses to the 2011 supplement to the Medical Board of California s mandatory survey of physicians, % Practice Organization PCPs and specialists were less likely to have Medi-Cal, Medicare, or uninsured patients than privately insured patients. While 73% of specialists had Medicare patients, only 60% of PCPs did. About 60% of PCPs and specialists had Medi-Cal patients. As the Affordable Care Act implementation and an aging population lead to more Medi-Cal and Medicare patients, access to care for these patients may become a challenge California HealthCare Foundation 19

20 Physicians, by Medical School Location and Specialty California, % 21% 32% Foreign Other US California Education and Training Only one-quarter of California s physicians attended medical school in the state. Nearly onethird of specialists were trained % 55% 43% in a foreign medical school % 24% 25% 0.0 All Physicians PCPs Specialists Note: Data include active MDs, excluding residents, fellows, and nonresponders (i.e., those MDs who did not respond to the MBC survey or opted to make their response private); 11% were nonresponders. Source: Medical Board of California Survey, May 2013; private tabulation California HealthCare Foundation 20

21 1300 Medical School Graduates California, 2003 to , , , , , , , , , , DOs MDs Education and Training The number of graduates from California s eight MD-granting universities has remained flat over the past 10 years. During the ,051 1,024 1, , ,049 1,055 1,078 same time, doctor of osteopathic medicine graduates increased 780 by 35%. By 2020, the number of graduates from MD-granting 520 schools should increase: University of California, Riverside, 260 enrolled its first class in 2013, and California Northstate Medical School is projected to begin Note: Data include medical school and osteopathic school graduates. Sources: American Association of Colleges of Osteopathic Medicine, Graduates by Osteopathic Medical College and Gender , Annual Osteopathic Medical School Questionnaires, through academic years, March 23, 2013, Association of American Medical Colleges, FACTS Table 27: Total Graduates by US Medical School and Sex, December 17, 2012, and accessed July 14, enrolling students in California HealthCare Foundation 21

22 Retention of Medical Students and Residents California vs. United States, 2012 percentage of Physicians Practicing in Same State Where Educated Education and Training California retained a high proportion of medical students 80 California United States who completed their education % 70% and residency in the state. California ranked first in the nation for medical school retention, and second (behind 40 47% Alaska) in resident retention % Medical School Residency Note: Data include medical school and osteopathic school graduates. Source: Association of American Medical Colleges, 2013 State Physician Workforce Data Book, Tables 17 and California HealthCare Foundation 22

23 Medical School Debt United States, 2013 Education and Training Over 80% of all medical school Graduates with Education Debt* 87% 84% $168,000 Median Total Debt $190,000 graduates had education debt. The median debt for private medical school graduates was $22,000 higher than the public medical school median Public Private Public Private *Education debt figures include premedical education debt. Source: Association of American Medical Colleges, Medical Student Education: Debt, Costs, and Loan Repayment Fact Card, accessed December 18, California HealthCare Foundation 23

24 Medical Student Specialty Choices Compared to Available Slots United States, 2013 percentage of seniors ranking this specialty only or first compared to available slots Orthopedic Surgery General Surgery Obstetrics/Gynecology Anesthesiology Radiology-Diagnostic Surgical Specialties Other Specialties 71% 74% 90% 84% 119% Education and Training Among US medical school seniors ranking residency choices, surgical specialties were more popular than primary care specialties. Seniors choosing family medicine as their first or only choice filled just 45% of the available slots. Emergency Medicine Physical Medicine and Rehabilitation Psychiatry Medical Specialties 57% 51% 90% Pediatrics Internal Medicine Family Medicine Primary Care 70% 51% 45% 45% Source: National Resident Matching Program, Results and Data: 2013 Main Residency Match, Washington, DC, California HealthCare Foundation 24

25 Employed Physician Earnings, Selected Specialties California, 2004 to 2012, Selected Years Income Incomes for family and general Primary Care Average Annual income % change to 2012 practitioners have risen sharply over the past eight years, Family and General Practitioners $119,010 $142,620 $182, % Internists, General $168,820 $172,560 $201, % Pediatricians, General $139,020 $156,830 $167, % Specialists Anesthesiologists $196,250 $209,900 $216, % Obstetricians/Gynecologists $181,070 $181,520 $220, % Psychiatrists $180,550 $155,190 $179, % Surgeons $168,220 $202,940 $209, % compared to other physician incomes and to the consumer price index. Other PCPs and specialists have seen a growth in income that roughly matches that of overall price increases, except for psychiatrist salaries, which Consumer Price Index (2004=$100,000 base) $100,000 $112,529 $120, % remained relatively flat, and anesthesiologist salaries, which have increased by only 10%. Notes: Does not include self-employed or physicians employed by government. Does not include ancillary income from sources such as directorships or call coverage. Source: Bureau of Labor Statistics, Occupational Employment Statistics Survey, accessed August 7, California HealthCare Foundation 25

26 Employed Physician Earnings, Selected Specialties California vs. United States, 2012 Average Annual income as a percentage of national average All Occupations 114% Income California physician incomes hovered around the national averages, without adjusting for Internists, General Obstetricians/ Gynecologists Psychiatrists Family and General Practitioners Pediatricians, General Physicians and Surgeons, All Other Anesthesiologists Surgeons 105% 102% 101% 101% 100% 99% 93% 91% California s higher cost of living. Compared to all occupations, California physician incomes were relatively lower than the national average Source: Bureau of Labor Statistics, Department of Labor, Occupational Employment Statistics Survey, stats.bls.gov/oes, accessed July 30, California HealthCare Foundation 26

27 Medicaid-Medicare Fee Index California vs. United States, 2012 Income Medi-Cal, California s Medicaid Index Relative to Medicare California United States program, is a poor payer RANKED # relative to other states Medicaid programs. For primary care and obstetric care, California ranked 48th amongst all states, and overall it compensated physicians 0.43 RANKED #48 RANKED #47 at only 51% of Medicare levels. RANKED #48 Primary Care Obstetric Care Other Services All Services Notes: The Medicaid-to-Medicare fee index measures each state s physician fees relative to Medicare fees in each state. The Medicaid data are based on surveys sent by the Urban Institute to the 49 states and the District of Columbia that have a fee-for-service (FFS) component in their Medicaid programs (only Tennessee does not). These fees represent only those payments made under FFS Medicaid. Sources: Kaiser Family Foundation, Medicaid-to-Medicare Fee Index, kff.org, accessed July 26, Estimated Medi-Cal beneficiary increase of 1.7 million obtained from the May 6, 2011 Medical Board of California Board meeting, California HealthCare Foundation 27

28 Medical Groups, by Type and Enrollment California, 2013 Medical Groups Nearly 280 medical groups Community Clinic 16% Foundation 7% Type of Group n=276 University of CA (2%) County Group 9% Group Practice 16% IPA 50% Community Clinic Foundation 7% IPA 28% Enrollment n=16.1 million 6% 4% University of CA (1%) County Group Group Practice 54% provided care to 16 million health maintenance organization (HMO) enrollees in California. While half of these groups were independent practice associations (IPAs), they accounted for only 28% of enrollment. Group practices, in contrast, represented only 16% of medical groups but 54% of enrollment; the disproportionate enrollment served by these groups was largely due to the Notes: Data include medical groups with at least six primary care physicians and that accept contracts directly from HMOs. Physicians frequently participate in more than one independent practice association (IPA). See Appendix B for definitions of medical groups. Segments may not add to 100% due to rounding. Source: Cattaneo & Stroud, 2013 Medical Group Survey, July 2013, accessed July 30, Permanente medical groups California HealthCare Foundation 28

29 HMO Physician Participation in Medical Groups, by Region California, 2012 Central Coast (n=5,762) Greater Bay Area (n=28,263) Inland Empire (n=7,570) Los Angeles County (n=28,966) Northern and Sierra (n=3,242) Orange County (n=9,109) Sacramento Area (n=6,462) San Diego Area (n=10,040) 1 Group 2 Groups 3 Groups 4+ Groups 79% 12% 6% 75% 13% 8% 4% 71% 11% 6% 12% 73% 10% 5% 12% 95% 4% 1% 1% 70% 10% 5% 15% 77% 10% 6% 7% 71% 13% 5% 11% 2% Medical Groups Of physicians that contracted with a health maintenance organization (HMO) (some 70% of all active physicians), Southern California s physicians were more likely to participate in multiple independent practice associations (IPAs), which are often not exclusive and allow for greater access to HMO contracts. San Joaquin Valley (n=7,307) California (n=103,832) 65% 20% 9% 6% 74% 12% 6% 9% Notes: Excludes solo practices. Segments may not add to 100% due to rounding. See Appendix A for a list of counties within each region. Source: Department of Managed Health Care, Timely Access Public Records request, 2012; private tabulation California HealthCare Foundation 29