• Announcements
• Events
• Areas of Research
• Current Projects

• Recent Publications

• Forthcoming Publications

• Submitted for Publication

• Archived Publications

California's Mental Health System

The California mental health care system is, by design, a system of 58 county-based mental health care systems, each of which has significant control over the financing and delivery of mental health care services. This gives the system the flexibility to address the widely varying levels of mental health indicators that exist in each county, as found in the Petris Center's 2004 report Measuring Mental Health in California's Counties: What Can We Learn? [PDF]

This flexible system is currently undergoing significant transformation with the passage in November 2004 of Proposition 63, the Mental Health Services Act (MHSA). Petris Center research explaining the passage of the MHSA, Millionaires and Mental Health: Proposition 63 in California, was published in Health Affairs in May of 2005. One of the goals of this landmark legislation is to establish evidence-based programs, known as Full-Service Partnerships, in every county in California. These programs are hoped to significantly improve outcomes for program participants. In keeping with the flexible county-based mental health care system, these programs will vary according to the specific needs of each county. With funding from the California HealthCare Foundation, the Petris Center is currently performing a three-year evaluation of the implementation of the MHSA, by examining the flow of funds, program and service changes, outcomes, and the process of change.

One of the key issues in the implementation of the MHSA is the whether the professional mental health workforce in California is sufficiently large in light of the expected growth in the demand for their skills. The professional mental health workforce in California has itself experienced a transformation and is now dominated by social workers and psychologists according to Petris Center research published in 2003 in Health Affairs entitled The Occupational Transformation of the Mental Health System.

California's Workforce

In California, the perennial issue with regard to the physician workforce is the distribution of physicians, both the overall adequacy of the physician-to-population ratio across geographical areas within California, as well as the special concern of promoting adequate opportunities for racial/ethnic matching between physicians and patients.

In September 2004, Louis W. Sullivan, former Secretary of Health and Human Services, (1989-1993), President Emeritus of the Morehouse School of Medicine, and Chair of the Sullivan Commission on Diversity in the Healthcare Workforce released the final report of the Sullivan Commission: Missing Persons: Minorities in the Health Professions. As part of the preparation for this report, the Petris Center was funded by the Kellogg Foundation via a subcontract from Duke University to produce a report for the Commission on the economic value of diversity in the physician workforce. The report, jointly produced by the Petris Center and the Center for Clinical and Genetic Economics at Duke University, The Economic Value of a Diverse Physician Workforce, was submitted to the Commission in May 2004. A revised version of this report has also been submitted to the journal Health Services Research under the title of Does the Market Value Racial and Ethnic Concordance in Physician-Patient Relationships? The results show that after taking into account the major factors that determine physician hourly earnings, the hourly earnings of Hispanic and Asian physicians are larger in areas where they are underrepresented relative to the size of the local Hispanic and Asian populations. This signifies that the market places a high value on Hispanic and Asian physicians who serve patients of like race/ethnicity.

In December 2004, the Petris Center published a report on physicians in California, entitled, Is There a Doctor in the House? An Examination of the Physician Workforce over the Past 25 Years. This work showed that while there is an adequate overall number of physicians in California, the uneven distribution of these physicians within California has resulted in many geographical areas of California being underserved. The report found no evidence that an increase in the penetration of health maintenance organizations (HMOs) was leading to an exodus of physicians from the state. The report pointed out that attention should be paid to the aging of the physician population and to the severe underrepresentation of Black and Hispanic physicians relative to the racial/ethnic makeup of the California population.

This report has influenced policymaking decisions regarding medical school programs by the UC Office of the President. Further research, using more rigorous methodology, examined the connection between HMOs and physician migration in California, and led to the publication of Do Physicians Always Flee from HMOs? New Results Using Dynamic Panel Estimation Methods in the journal Health Services Research in April 2006. This paper shows that while specialist physicians do tend to move away from areas where there is growing HMO penetration, this effect is reversed as long as the economy in a given California county is at least 5% better than the U.S. average. Further, no movement related to HMO penetration was found for primary care physicians.

The experience of the Petris Center in studying physician labor markets and physician migration led to the production of the forthcoming Petris Center report, Designing Policies to Improve Medical Care for Underserved Minority Populations in California, funded by the California Program on Access to Care. The results from this project include the finding that over one-fifth of California's Black physicians and nearly one-third of it's Hispanic physicians currently practicing in California are coming from large states, such as Illinois, Texas, and New York. It also found that that when considering migration within California, Black and Hispanic physicians are more likely to leave areas where they are already underrepresented. However, this does not hold true for Asian physicians. In addition, when Black, Asian, and Hispanic physicians move, they tend to move to areas similar to those they left, rather than to areas where they are more underrepresented. This suggests that the current distribution of minority physicians is unlikely to improve without policy intervention.

These results and others will be discussed in Richard Scheffler's forthcoming book, Is There a Doctor in the House? The Supply Cycle of Doctors (UC Press).

Pharmaceuticals

Two significant issues with regard to pharmaceuticals are access to pharmaceuticals and the inappropriate prescribing of pharmaceuticals. In November 2005, a special election was held that included Propositions 78 and 79, which, along with Senate Bill 19 and Assembly Bill 75, addressed the lack of access to prescription drugs for the uninsured. Research jointly sponsored by the Pharmaceutical Research and Manufacturers of America (PhRMA) and the Petris Center examined the question of how many uninsured people there actually are in Californian who need help getting prescribed medications. The study also assessed the programs, public and private, available to provide pharmaceuticals to low-income individuals. The Petris Center report, Uninsured Californians and Access to Prescription Drugs, found that different data sources yielded widely varying estimates in the uninsured rate, and determined which data source was the most reliable. The report also listed the various public and private programs providing pharmaceuticals to low-income individuals and analyzed a major category of these programs, Patient Assistance Programs. Patient Assistance Programs were estimated to provide pharmaceuticals to approximately 5% of uninsured Californians.

An important issue is the inappropriate prescribing of pharmaceuticals. Significant concern has been raised with regard to the wide variation in the rates of prescribed psychostimulant drugs for Attention-Deficit/Hyperactivity Disorder (ADHD) across the U.S. Variation in psychostimulant drug use across communities ranges from 1.7% to 26%. ADHD is the most commonly diagnosed behavioral disorder in children, making up more than 50% of all child psychiatric diagnoses, as between 3% and 5% of U.S. school-age children are estimated to have ADHD. As it is unlikely that such wide variations have a biological basis, the Petris Center has been funded for three years by the National Institute of Mental Health (NIMH) to study the economic, policy, and social factors that may be responsible for the wide variation in psychostimulant use across the U.S., particularly, in what situations and geographical areas psychostimulant drugs may be overprescribed or underprescribed.

Early work for this project includes An Analysis of the Significant Variation in Psychostimulant Use across the U.S., published in 2005 in the journal Pharmacoepidemiology and Drug Safety, which shows that counties with above median levels of psychostimulant use have significantly greater population, higher per-capita income, lower unemployment rates, greater HMO penetration, more physicians per capita, a higher ratio of young-to-old physicians and a slightly higher students-to-teacher ratio. Work on the cost of children with ADHD in Northern California, Attention-Deficit/Hyperactivity Disorder in Children: Excess Costs Before and After Initial Diagnosis and Treatment Cost Differences by Ethnicity, currently under review at the Archives of Pediatrics & Adolescent Medicine, shows that compared to children without ADHD, children with ADHD have significantly higher health services costs both before and after diagnosis. The high level of expenditures spent on ADHD is reflected in global expenditures on ADHD medications, which were $2.4 billion in 2003, representing a nine-fold increase since 1993. Ninety-three percent of these expenditures are attributable to the U.S. as noted in The Global Market for ADHD Medications, which has been submitted to Health Affairs. However, this rise in cost may not continue as the U.S. market appears to be quite sensitive to the price of psychostimulant drugs as found in Area Variation in Psychostimulants Use to be submitted shortly to the New England Journal of Medicine.

Social Capital

The effect of the community social environment on health is a young and growing concept in the field of public health. Researchers have developed the concept of social capital as an important feature of social environments, one that may be related to health outcomes.

Individual social capital can be defined as the level of trust, networking, or cooperation that an individual has in/with the larger society. Community social capital can be defined as the aggregate level of trust, networks, or cooperation within a given community. The Petris Center was awarded a grant by the Centers for Disease Control and Prevention in 2002 to study the effect of social capital on cardiovascular health in California. This project led to the paper, Community Social Capital and Recurrence of Acute Coronary Syndrome: A Cohort Study Among Members of a Large Integrated Health Care Delivery System in Northern California, USA, which is to be submitted shortly to the medical journal Lancet. This work, done in collaboration with researchers at Kaiser Permanente Northern California and Harvard University, found that higher levels of community social capital are associated with a lower recurrence of chest pain and heart attack among lower-income individuals.

As part of this work, the Petris Center developed a new measure of social capital, the Petris Social Capital Index (PSCI). The PSCI measures community social capital resources, in other words, resources that facilitate the development and maintenance of community social capital. The PSCI has been validated and shown to be relevant to cardiovascular risk factors such as smoking, psychological stress, exercise, and the consumption of fruits and vegetables. This validation work has led to the publication of The Empirical Relationship between Community Social Capital and the Demand for Cigarettes in the journal Health Economics, which found that higher levels of community social capital are associated with a reduction of the number of cigarettes consumed by smokers. An additional paper, Community Social Capital and Smoking Cessation, which shows that community social capital is positively related to smoking cessation, is to be submitted shortly to the journal Tobacco Control. Documentation of the association between community social capital and mental health is found in the paper, The Role of Community Social Capital in Reducing the Prevalence of Serious Mental Illness, which is shortly to be submitted to the journal Social Science and Medicine. Other Petris working papers on this topic include Community Social Capital, Individual Social Capital and Obesity.

Further exploration of the mechanisms by which community social capital reduces smoking has been funded by the Tobacco-Related Disease Research Program. This project is currently underway and will continue into 2007.

California's Hospitals

Hospitals in California have been undergoing a transformation through industry consolidation, resulting in large-scale hospital closures and significant changes in hospital ownership since the mid 1990s. The Petris Center has provided key data on these changes, including important studies on hospital charity care. The Petris Center has done in-depth research on the charity care situation in California hospitals, hosting the conference on hospital charity care in October 2001, sponsored by the California Program on Access to Care, which drew over 80 participants representing the research, hospital, health care, government, labor, foundation, and advocacy communities. The Petris Center reports Hospital Charity Care: Recent Research on Defining, Policy, and Market Impact and The Hospital Charity Care Conference Reader [PDF] were released during this conference.

In December 2001, the Petris Center released the report, California's Closed Hospitals, 1995-2000, which documented the distribution and characteristics of closed hospitals as well as reasons for closure. The report found that during the research period 23 hospitals had closed, 11 of which were for-profit.

The Petris Center followed up the above work with the release of the report Hospital Service Changes in California: Trends, Community Impacts, and Implications for Policy in 2004, which led to the publication of the article Changes in Service Availability in California Hospitals, 1995 to 2002 in the Journal of Healthcare Management in January of 2006. This study expanded the research focus of the Petris Center beyond the closure of hospitals to the closure of services within hospitals, finding that few hospitals both closed and opened services and that the service closed most often was Obstetrics. Inpatient Rehabilitation was the most frequently opened service.

California's Health Care Market

Health care markets work best for consumers when prices are low and there are many providers to choose from. These characteristics can be compromised when the bargaining power of hospitals, health plans, and medical groups becomes too concentrated, resulting in higher prices and the reduction of choice for consumers. The Petris Center working paper Physician Market Concentration and Antitrust in California shows that there are a number of highly concentrated physician markets in California, with several medical groups falling outside of antitrust safety zones.

The importance of the issue of market concentration in California led the Petris Center to host the 2004 conference Antitrust and Health Care: Assessing Issues for California and the United States. The conference included the presentation of papers and discussion during four sessions: (1) The State of the Health of California's Health care Markets: Current Research on Hospitals and Related Markets Closures, Consolidation of Services, and Market Co-evolution; (2) The Evolution of Physician Markets: Competition, Networks and Collective Bargaining; (3) Incorporating Variations in Health Care Quality into the Measurement of Market Power; and (4) Future Directions and Topics within Antitrust and Health.

Oral Health Care in California

In September 2005, the California Dental Association Foundation (CDAF) approached the Petris Center for assistance in a major study they had undertaken to assess whether there was a shortage of dental auxiliaries (hygienists and assistants) in California. They asked Petris to add an economic analysis to the survey results on dental auxiliaries that had been produced by the UCLA Center for Health Policy Research (CHRP). The joint study with UCLA, Is There a Shortage of Dental Hygienists and Assistants in California? was released in November of 2005. The Petris Center's section, An Economic Analysis of the Labor Market for Dental Hygienists and Dental Assistants in California: 1997 - 2005, definitively found that while there had been a shortage of both dental hygienists and dental assistants beginning in the late 1990s, these shortages had been resolved well before the beginning of 2005. A revised version of this report, How Do We Measure Shortages of Dental Hygienists and Dental Assistants? Evidence from California: 1997-2005 has been submitted to the Journal of the American Dental Association.

The Petris Center is currently developing an additional project with the California Dental Association Foundation to study the current oral health status of Californians as well as issues of access to oral health care services. This will be the first such wide-ranging project done on the issue of oral health in California.