The 2020-21 Budget: Medical Education Analysis

The 2020-21 Budget: Medical Education Analysis Summary Governor Proposes Augmenting Funding for Two University of California (UC) Medical Schools. For the UC Riverside School of Medicine, the Governor proposes a $25 million ongoing General Fund augmentation to support operations and expand enrollment. In conjunction, the Governor proposes approving a $94 million project to construct a new Riverside medical education building. At the UC San Francisco (UCSF) Fresno branch campus, the Governor proposes $15 million ongoing General Fund, also to support operations and expand enrollment. According to UC staff, UCSF Fresno intends to submit an expansion plan in March. Proposals Raise Questions About How Best to Address Regional Physician Shortages. The Inland Empire and San Joaquin Valley have significantly fewer physicians per capita than other regions in the state. Providers in these regions appear to be responding, with both regions seeing increases in medical school enrollment and physician residency slots. Analysis is lacking as to whether these trends will be sufficient. To the extent they are not, the Legislature has options to further increase physician supply. In recent years, the state has increased funding for physician residency and physician incentive programs (such as loan repayments). These initiatives tie funding more closely to the end of the physician pipeline. They might be more cost-effective policy responses than expanding medical school enrollment to attract physicians to certain geographic areas, but data are lacking to fully compare their relative effectiveness. Riverside Proposal Could Be Improved. If the Legislature is interested in expanding medical school enrollment at UC Riverside, we recommend two improvements. First, we recommend setting enrollment targets and aligning state funding. For example, rather than giving the school an augmentation all at once in 2020-21 (even though the school does not plan to begin growing enrollment until 2023-24), the Legislature could provide the first augmentation in 2022-23 and then spread further augmentations over several subsequent years. Second, we recommend the Legislature inquire about the school’s expansion plans during spring hearings. Under the current plan, some of the proposed augmentation would supplant campus and UC support for the school. If the freed-up funds would be used for low legislative priorities, the Legislature could reduce the proposed augmentation or designate that the funds support enrollment beyond the school’s current plan. In either case, the signal would be that the campus should not reduce its existing support for the school. UCSF Fresno Proposal Requires Further Planning and Review. The UCSF Fresno proposal also provides funding without first setting enrollment expectations. Additionally, the proposal lacks a fully developed expansion plan and facility assessment. Furthermore, according to UC, the forthcoming UCSF Fresno plan will propose establishing a new joint medical program with UC Merced, but this is only one of many options UCSF Fresno has explored the past few years. Given the complex and long-term consequences at stake, we recommend the Legislature withhold action until it has received a detailed plan and held an oversight hearing to vet it. GABRIEL PETEK LEGISLATIVE ANALYST FEBRUARY 20, 2020 analysis full gutter 2020-21 BUDGET INTRODUCTION In this brief, we analyze the Governor’s proposals and build a new academic building at the UC relating to UC medical education. After providing Riverside School of Medicine. We then analyze an overview of medical education, we first analyze the Governor’s proposal to expand enrollment and the Governor’s proposals to expand enrollment services at the UCSF Fresno branch campus. OVERVIEW The Governor’s proposals would expand UC Medical Education medical education programs in an effort to increase Becoming a Doctor Entails Long Education physician supply in two regions of the state. In this Pathway. As Figure 1 shows, students first section, we provide an overview of both medical complete basic science preparatory work as education in California and physician workforce undergraduate students. They then complete four issues. years of medical school, typically consisting of Figure 1 The Typical Pathway to Becoming a Physician in California Is Long Obtain Undergraduate College Bachelor’s Typically four years with courses in biology, Degree physics, chemistry, and other subjects Medical School Two years of clinical experience Two years of courses in science and clinical care Stage 2 of Licensing Exam Stage 1 of Licensing Exam Depending on specialty, Post Graduate Training Obtain additional years of residency Three years of residency License and fellowships Obtain Certification Stage 3 of Licensing Exam Certification Exams 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET two years of basic science instruction and two many clinical faculty to oversee students as they years of clinical experience. After medical school, undertake their clinical rotations during their third students complete postgraduate training known as and fourth years of medical school. residency in a specific medical area, such as family Medical Education Is Subsidized by Clinical medicine or surgery. Though state law only requires Revenues and Public Funds. Medical schools three years of residency to receive a license, most rely on many sources to fund instruction, research, medical students complete additional years of and clinical training. Many medical schools training to receive industry-recognized certification subsidize costs from clinical revenues earned by in a specific medical area. their faculty, who often have dual appointments California Has Numerous Public and Private working as active physicians at their medical Medical Education Programs. California has center. UC medical schools also cover operations 13 medical schools (6 public schools and 7 private with state General Fund and student tuition. At schools) enrolling 7,400 students. In addition, UC, total annual resident tuition and fee charges California has 12,700 physician residents trained range from $36,021 at UCSF to $41,231 at UC by nearly 100 sponsors. Residency sponsors Davis. In contrast to medical schools, virtually no consist of medical schools, hospitals, and other state General Fund directly subsidizes residency medical providers. In both California and across the programs. Instead, residency programs in California nation, the number of residency slots exceeds the and across the nation cover their operating costs number of medical school slots. To fill residency using primarily clinical revenues and federal funds. slots, sponsors rely on graduates not only from Accrediting Bodies Set Standards. UC medical California and other states but from Canada and schools are accredited by the Liaison Committee other countries. In California, UC is the sole public for Medical Education (LCME), and residency higher education institution tasked with providing programs are accredited by the Accreditation medical education. Six UC campuses—Davis, Council on Graduate Medical Education (ACGME). Irvine, Los Angeles, Riverside, San Diego, and San Like many other accrediting bodies, LCME and Francisco—operate medical schools and residency ACGME are peer-run, consisting of member programs. As Figure 2 shows, UC educates almost medical schools and residency programs half of medical school students and trains almost throughout the country. A chief concern of both half of physician residents. Medical Education Is Figure 2 Relatively Costly. Available Almost Half of California's data suggest medical education Medical Education and Training Occurs at UC likely is the most costly form of 2018-19 instruction in higher education, with costs ranging from high tens of thousands of dollars to hundreds of thousands of dollars per student. The high cost is largely due to very low overall student-faculty ratios and high 12,700 7,400 Medical UC faculty compensation. Most UC Residents Students medical schools hire more faculty than students, with an average Other student-faculty ratio of 0.5. That Institutions is, medical schools, on average, Other hire two faculty members for each Institutions medical student. The ratios are driven primarily by the need for www.lao.ca.gov 3 analysis full gutter 2020-21 BUDGET bodies is to ensure programmatic funding and assistants) by 2030. In one of our 2019 reports, resources are adequate to support enrollment. we found that psychiatrist wages have grown When programs wish to expand enrollment or slots, much faster than other occupations since 2010, a they are expected to notify LCME and ACGME of potential indicator of a shortage. (In contrast, we their plans. If these accrediting bodies determine did not find data indicating a shortage among other schools and programs lack adequate resources, mental health professionals, such as psychologists they can request more information, undertake and social workers.) further review, or consider various sanctions. Data Show Longstanding Regional Disparities in Supply of Physicians. According to most Physician Workforce estimates, the state’s inland regions—the Inland California Has Over 110,000 Licensed Empire, Central Valley, and Northern California— Physicians. Of these physicians, researchers have notably lower numbers of physicians and other estimate around 28,000 are employed in a primary health care providers per capita than the state’s care medical area—generally defined as family coastal regions. For example, a 2017 study from medicine, general internal medicine, general researchers at UCSF estimated that the primary pediatrics, and obstetrics/gynecology. Physicians care provider to population ratio in the Bay Area is in these areas are considered to be the first point more than double the ratio in the Inland Empire. of health care for patients. The state’s remaining State Funds Three Types of Programs in physicians are employed in numerous specialty Response to Physician Shortages. First, a portion areas, such as psychiatry or surgery. In addition of UC medical students are enrolled in specialized to physicians, patients can receive health services medical education programs focused on providing from a variety of other providers. For example, care to certain communities (such as disadvantaged California has around 29,400 nurse practitioners populations or rural communities). These programs and physician assistants. Patients can also are known as Programs in Medical Education receive mental health services from psychologists, (PRIME). Second, the state funds competitive grant case workers, and other providers. These other programs for physician residency programs. To providers generally have narrower scopes of qualify for these state grants, residency programs practice than physicians. For example, physicians must focus on primary care, emergency medicine, have significantly greater authority than these other or psychiatry, and demonstrate they are serving providers to prescribe medication. certain geographic areas of the state. Lastly, the Some Data Suggest California Is Facing state has expanded a variety of incentive initiatives Shortages in Certain Medical Fields. Available (such as loan repayments and stipends) to attract data suggest that shortages are concentrated new physicians to work in shortage areas. To date, among primary care physicians and psychiatrists. the Legislature has lacked adequate information to Specifically, a 2017 study from researchers at gauge the relative cost-effectiveness of the three UCSF estimated California could face a shortage types of programs (medical school programs, of around 4,100 primary care providers (including physician residency programs, and fiscal incentive physicians, nurse practitioners, and physician programs) at increasing the supply of physicians in underserved regions. UC RIVERSIDE SCHOOL OF MEDICINE In this section, we provide background on Background UC Riverside’s School of Medicine, describe the UC Riverside Is UC’s Newest Medical School. Governor’s proposals to expand the school, assess Prior to operating a medical school, the Riverside the proposals, and offer issues for consideration. campus provided basic science instruction to a 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET relatively small number of medical students. After square feet dedicated to its instruction and two years of study, the students then completed administrative functions. The space includes one their clinical rotations at UC Los Angeles. In 2008, main education building, associated on-campus the UC Board of Regents authorized the Riverside modular space, a small amount of instructional campus to run a full medical school. Though space in the campus’s science library, and approved by the board in 2008, several years of off-campus leased office space for faculty and planning elapsed prior to the school enrolling its staff. In the 2019-20 budget, the state adopted first cohort in 2013-14. The delay was largely due provisional language authorizing UC to “pursue a to challenges with the school receiving preliminary medical school project at the Riverside campus.” accreditation from LCME. The school eventually Associated intent language indicated the state received preliminary accreditation in 2012 and would increase UC’s General Fund support in future became fully accredited in 2017. years to finance the project. School Relies on Surrounding Hospitals for Proposals Its Clinical Training. The Riverside campus differs from the other UC medical schools in that it does Provides $25 Million Ongoing to Expand not operate its own medical center. To offer clinical Riverside School of Medicine. The Governor’s placements for its students and sponsor residency Budget Summary indicates that the purpose of the programs, the Riverside medical school partners proposed augmentation is to enhance the school’s with nearby hospitals and clinics. Physicians operational support and expand enrollment. at these medical centers provide the clinical Budget provisional language further states that the instruction, with about 60 percent of them providing funds are to supplement and not supplant existing instruction on a voluntary, unpaid basis. funds provided by UC for the medical school. The School Now Receives Funds From budget does not state a specific enrollment target. Multiple Sources. The 2013-14 state budget According to UC staff, the Riverside campus would provided $15 million ongoing General Fund like to grow its incoming medical school cohort to the school. While the school considers this size from 77 students to 125 students. As Figure 3 annual appropriation to be an important source (see next page) shows, the school would not begin of operating funding, the school’s budget has growing the number of incoming students until the since grown significantly. In 2019-20, the school 2023-24 academic year. The campus projects its anticipates receiving $75 million in total funding, medical school enrollment would eventually reach with almost half coming from clinical revenues. around 500 students (four cohorts consisting of 125 students each) by 2027-28. Campus and UC Office of the President Contribute Funding to the School. In recent Proposes Approving New Medical School years, the Riverside campus and UC Office of the Facility. UC submitted a proposal for a new President have provided funds to the school to help UC Riverside medical education building in cover its operating costs. For 2019-20, the School September 2019. As Figure 4 (see next page) of Medicine reports contributions from the Riverside shows, the proposal is for the medical school campus, UC Office of the President, and campus to maintain its existing education building but reserves. As reserves are generally best suited to stop using its existing off-campus leased space cover one-time costs, rather than operations, the and replace its on-campus modular buildings. Riverside campus has characterized the School In addition to constructing a new building, the of Medicine as having a budget deficit. Both the medical school proposes renovating some space campus and the medical school would like to in its science library. UC is seeking $94 million discontinue the school’s reliance on reserves for in bond authority to support working drawings covering ongoing operating costs. and construction costs. When UC begins paying associated debt service (expected in 2023-24), State Preliminarily Authorized New Medical the annual cost would be $6.8 million, paid over School Building. Currently, the Riverside medical 30 years. Under UC’s debt service projections, the school has a total of around 39,000 assignable www.lao.ca.gov 5 analysis full gutter 2020-21 BUDGET Figure 3 Under Proposal, UC Riverside Would Gradually Increase Medical Student Enrollment Proposed Time Line of UC Riverside Expansion, Number of Students 600 500 400 Total Enrollment 300 200 First-Year Students 100 2019-20 2020-21 2021-22 2022-23 2023-24 2024-25 2025-26 2026-27 2027-28 July 2020 February 2022 Summer 2023 Summer 2024 Receive budget Receive LCME Enroll cohort Enroll cohort augmentation determination of 100 students of 125 students Spring 2021 August 2021 Spring 2023 Begin construction of Notify LCME of Begin occupying new education building expansion plans new building LCME = Liaison Committee on Medical Education. total cost to pay off principal and interest would be Assessment $204 million ($94 million principal and $110 million Region’s Medical Schools and Residency interest). Programs Appear to Be Responding to Shortage. In Figure 4 recent years, both medical schools Proposed Facility Project Would Increase and residency programs in the UC Riverside School of Medicine Space Inland Empire appear to be taking steps to increase physician supply Prior to After Project Project Completion in the region. As Figure 5 shows, the Inland Empire has two private Space (asf) medical schools. One of these New education building — 65,000 schools—the California University Existing education building 19,829 19,829 Orbach Library 1,946 10,946 of Science and Medicine— Modular building 4,659 — opened recently and is growing Leased off-campus space 12,600 — enrollment. Furthermore, Western Totals 39,034 95,775 University, located just outside of Students 292 500 the region in nearby Pomona, has Space per student 134 192 grown enrollment considerably Note: Excludes School of Medicine’s research and health clinic space, which would remain over the past several years. At unaffected by the proposal. both schools, California students asf = assignable square feet. comprise over 80 percent of 6 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET incoming students. Residency slots have also to general appropriations to medical schools, these increased notably in the region in recent years. other types of programs tie funding to attracting According to national residency match data, the physicians to practice in high-need medical areas number of first-time resident slots in the Inland and geographic areas. As noted earlier, the lack Empire grew 58 percent between 2015 and 2019. of more comprehensive data on these initiatives Analysis is lacking as to whether these recent hinders the Legislature’s ability to assess their developments are sufficient to address gaps in the relative cost-effectiveness in addressing regional Inland Empire’s regional supply of physicians. physician shortages. Impact of Proposal on Increasing Physician School’s Initial Plan Supplants Existing Supply in Inland Valley Could Be Small. As the Funding. The UC Riverside School of Medicine’s Governor’s proposal would increase the school’s budget plan would have a portion of the proposed incoming cohort from around 80 students to $25 million General Fund augmentation replace 125 students, the proposal would increase the existing campus and UC Office of the President number of medical schools graduates in the state support for the school. (In future years, the school by about 45 graduates annually. According to plans to maintain a balanced budget primarily by UC Riverside, about one-third of its medical school increasing its clinical revenues and student tuition graduates currently remain in the Inland Empire revenue as it grows its staffing and enrollment.) for their residency program. The school notes that Potentially, the campus could use the freed-up this retention rate could change in the future, but redirected funds in areas that are of lower priority to the current rate would result in about 15 additional the Legislature than the medical school. physician residents in the Inland Empire annually. Given that the Figure 5 school’s first cohort only recently graduated from medical school Several Medical Schools Now Operate in the Region and many from that graduating Total Medical School Enrollment in 2019-20, Unless Otherwise Noted class are still in their residency programs, it is too soon to evaluate how many UC Riverside students ultimately will practice California University of University of Western Science and Medicine medicine in the region. Southern California University 162 Students 812 Students 917 Studentsa Other Approaches Might Be Loma Linda 724 Students UC Los Angeles More Effective at Increasing 856 Students UC Riverside Physicians in the Inland Empire. 292 Students While increasing medical school enrollment likely is an effective UC Irvine 477 Students way to increase the statewide supply of physicians, programs that target funds toward the end UC San Diego 622 Students of the medical education pipeline could have stronger regional effects. For example, the state a Enrollment in 2018-19, the most recent year available for this school. in recent years has increased funding for primary care residency Note: Kaiser Permanente is accredited to open a medical school in Pasadena (Los Angeles County), with the first cohort expected to start in 2020. programs and certain physician incentive programs (such as loan repayment programs). In contrast www.lao.ca.gov 7 analysis full gutter 2020-21 BUDGET Recommendations funds would be used for low legislative priorities, the Legislature could correspondingly reduce If Proposal Is Pursued, Enhance the proposed augmentation. Alternatively, the Accountability. The Governor’s proposed Legislature could retain the size of the proposed provisional language associated with the $25 million augmentation but designate that the funds support General Fund augmentation does not establish an additional enrollment beyond the school’s current enrollment target for the UC Riverside School of expansion plan. In either case, the Legislature Medicine. Were the Legislature to decide to fund would be signaling that the campus should not enrollment growth at the school, we recommend reduce its existing support for the medical school. it set enrollment targets and specify the period of Consider Capital Proposal in Context of time over which the school has to meet the targets. School’s Expansion Plan and Competing The Legislature also might consider aligning the Capital Priorities. Given that the primary rationale timing of any General Fund augmentation with to construct a new facility at UC Riverside is to the school’s enrollment growth plans. Under this support medical school enrollment growth, we approach, the state would ramp up funding as the recommend the Legislature ensure that the school’s school’s enrollment grows, rather than allocating it plan to expand its operations is well aligned with all at once in 2020-21. For example, the Legislature its capital expansion plan. We also encourage the could commence enrollment growth funding in Legislature to keep UC’s other capital priorities 2022-23 (one year prior to the school enrolling in mind. As we discuss in other higher education a larger student cohort), then spread further reports, UC faces many high-priority seismic augmentations over several subsequent years. renovation and maintenance needs that will likely Request School Report During Spring place budget pressure on the Legislature for many Hearings on How It Plans to Use Redirected years to come. Were the Legislature to deem this Funds. To ensure any General Fund augmentation medical school project to be high priority in the for the school meets legislative priorities, it will be context of all the university’s and state’s needs, the important for the Legislature to better understand Legislature could consider the project a potential how the Riverside campus would spend any candidate for Proposition 13 (2020) funds were the redirected funds. To the extent the redirected measure to pass in March. UCSF FRESNO In this section, we provide background on to a Fresno medical center. UC reports that the the UCSF Fresno branch campus, describe the current site hosts around 150 medical students Governor’s proposal to expand the branch campus, in clinical rotations and sponsors 320 physician assess the proposal, and offer a recommendation. residents. Throughout UCSF Fresno’s history, some of its activities have occurred on site and some in Background community hospitals. UCSF Has Operated Medical Education UCSF Fresno Also Supports San Joaquin Programs in Fresno Since 1970s. In 1975, Valley PRIME Program. In 2011, UC established the state provided one-time funding to establish a new PRIME program focused on practicing UCSF Fresno. Over the years, UCSF Fresno has medicine in the San Joaquin Valley. Under the supported third-year rotations for medical students program, known as San Joaquin Valley PRIME, from UC Davis and UCSF as well as physician medical students completed their two years residents. In 2001-02, the state appropriated funds of basic science instruction at UC Davis, then to construct a new Fresno facility to house these completed one year of clinical rotations at UCSF programs, and, in 2005, UCSF Fresno moved Fresno, before returning to UC Davis to complete into the new 87,700 square foot facility adjacent their second year of clinical rotations. According 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET to UC, the San Joaquin Valley PRIME program students would be enrolled at UC Merced and enrolled cohorts of 8 students annually (with 100 students at the Fresno branch campus. around 32 students enrolled across four years). In UCSF Has Taken Initial Steps Toward 2015-16, the state provided $1.9 million ongoing Expansion. In 2018, UCSF received accreditation General Fund for the program. The authorizing from LCME for the Fresno operations to become legislation—Chapter 2 of 2016 (AB 133, Committee a branch campus and begin supporting two years on Budget)—stated that the program should of rotations (rather than only one). The following enroll 48 students. That is, the funding grew the year, UC Davis transferred administration of the program’s enrollment from cohorts of 8 students San Joaquin Valley PRIME program to UCSF. For (or 32 students across 4 cohorts) to cohorts of the first cohort in 2019, consisting of six students, 12 students (or 48 students across 4 cohorts). UCSF is taking the hybrid approach. Specifically, Because of the timing of the appropriation, PRIME students complete basic science instruction UC Davis did not begin spending the funds until the at the UCSF main campus, with portions of their 2016-17 academic year. time (such as weeklong experiences and summer A Couple of Years Ago, UC Began Studying research projects) spent at Fresno. The students Possible Expansion of Fresno Programs. In then complete all clinical rotations at Fresno. UCSF 2017, the UC Office of the President funded a plans enrolling a cohort of 12 students in 2020-21, third-party study of options to expand medical returning the program to its previous enrollment education at UCSF Fresno. The study assumed level. UCSF would administer the San Joaquin Valley Last Year, Legislature Expressed Intent to PRIME program, grow the program’s enrollment Approve a Future UC Merced Medical Facility. to cohorts of 50 students annually (200 students In addition to approving a UC Riverside medical across 4 years), and provide a greater portion of school project, the 2019-20 budget authorized UC instruction in Fresno. The study developed three to pursue a new medical school project at or near options to fulfill these objectives, described below: the Merced campus. As with the Riverside project, • Hybrid Model. Under this approach, students the language stated intent to increase UC’s General first would complete their two years of basic Fund support in future years to finance the project. science instruction at UCSF’s main campus, To date, UC has not submitted a Merced facility then complete their two years of clinical proposal for the state to review. rotations at Fresno. Each year, 100 students Proposal would be enrolled at the UCSF main campus and 100 students at the Fresno branch Provides $15 Million Ongoing for UCSF campus. Fresno. Provisional language in the budget • Full Branch Model. Under this approach, states the funds are available to support UCSF students would complete all four operational costs and expand services at UCSF years—both basic science and clinical—at Fresno, in partnership with UC Merced. Similar Fresno (for an annual total of 200 students at to the provisional language for the Riverside Fresno). The study further considered options augmentation, provisional language for this for faculty to use technology to remotely augmentation states the funds shall supplement deliver instruction to Fresno students from the and not supplant existing funds provided by UC for UCSF campus. the Fresno branch campus. • Joint Model. Rather than beginning UC Plans to Submit More Detailed Proposal instruction in San Francisco or Fresno, under in March. In correspondence with our office, UC this approach UCSF students would complete indicated that it would submit a more detailed basic science instruction at the Merced budget of its expansion plans for UCSF Fresno in campus. Students would then complete March. According to UC, its proposed budget will clinical rotations at Fresno. Each year, 100 outline a somewhat different expansion plan than www.lao.ca.gov 9 analysis full gutter 2020-21 BUDGET the three options described in the 2017 study. were the Legislature to receive a detailed budget Under the revised plan, UC would develop a joint plan in March, we question whether the Legislature bachelor’s/medical degree program between would have adequate time to weigh such complex, UC Merced and UCSF. Students enrolled in the costly, multifaceted, and impactful considerations joint program would complete their four years of prior to enacting the budget in June. undergraduate studies at UC Merced. Students UC Riverside Experience Serves as a would then complete basic science medical Warning. The Governor’s approach to expanding school instruction at Merced and move to UCSF UCSF Fresno appears to share several Fresno for their clinical rotations. According to disconcerting similarities to the state’s approach to UC, the program could serve as the foundation to establishing the UC Riverside School of Medicine. eventually create an independent medical school at Similar to the approach taken for UC Riverside, the Merced campus. UC states its initial plan is to the Governor proposes providing funding without enroll the first cohort of undergraduate students at first setting enrollment expectations, having a UC Merced in 2022. developed budget plan, or assessing facility needs. Furthermore, when our office asked the Department Assessment of Finance the basis for the proposed $15 million Workforce Issues Are Similar to Those Raised funding level, it noted that the state provided by Riverside Proposal. Similar to the Inland the same amount to UC Riverside in 2013-14. Empire, the San Joaquin Valley is set to see growth Given UC Riverside’s previous implementation in private medical school enrollment. Though the delays, current budget shortfalls, and notable cost region currently has no medical schools, one new pressures, we encourage the Legislature to take a private school in Clovis plans to enroll its first more gradual, cautious, and vigilant approach to cohort in 2020. The region also has experienced a expanding UCSF Fresno. notable rise in residency slots, with slots growing Recommendations by 54 percent between 2015 and 2019. Analysis is lacking as to whether these recent developments Withhold Action Pending Comprehensive are sufficient to address gaps in physician supply UCSF Fresno Expansion Plan. We recommend within the San Joaquin Valley. As with the Riverside the Legislature withhold taking action on this proposal, the Legislature also would want to weigh proposal until it receives and has had time to the efficacy of medical school expansions against carefully review any expansion plan that UCSF funding more residency slots or incentive programs. Fresno submits. At a minimum, we recommend the Legislature Faces Complex Considerations. plan include: Were the Legislature to conclude that further • A summary of different options to expand expanding medical student enrollment in the the center, including prioritizing existing region is warranted, it would want to decide how enrollment and clinical slots for San Joaquin to undertake the expansion. The Legislature Valley-focused students, expanding UCSF cannot fully assess the Governor’s proposal until Fresno into a four-year branch campus, and it receives UC’s expansion plan. Ideally, such a establishing a joint program with UC Merced. plan would summarize available medical school • For each option, a time line of planning expansion options, along with their associated activities, including staffing and enrollment annual operating and capital costs through levels and implementation deadlines. full implementation. The plan also would offer alternative approaches to meeting regional • For each option, an estimate of the total workforce needs, including the possibility of operating cost and a multiyear expenditure increasing residency slots or physician relocation phase-in plan, along with revenue projections incentives. Additionally, any expansion plan by source. should have an implementation time line that has • A space and facility utilization analysis of projections of staffing and student enrollment. Even UCSF’s main campus and the Fresno branch 10 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2020-21 BUDGET campus, along with a capital outlay plan under Recommend an Oversight Hearing to Review each option that identifies scope, cost, and and Discuss Any Expansion Plan. After receiving schedule. a comprehensive expansion plan, we recommend the Legislature hold an oversight hearing to vet the If the university is unable to provide this information plan. We believe such a review is critical given the by spring, the Legislature could create a reporting issues at stake are complex, potentially costly, and requirement (in provisional budget language or could have significant implications for people living supplemental reporting language). We recommend in the region. As the Legislature carefully reviews selecting a due date for the report that is aligned the proposal, we would note that certain expansion with the legislative budget process. For example, efforts will already be underway in the region. With were the Legislature interested in funding expansion a new medical school opening and UCSF Fresno in 2021-22, it would want the UC report no later in the midst of increasing enrollment in the San than November 2020. Joaquin PRIME program, enrollment expansion will happen in 2020-21 even without the Legislature approving further expansion efforts. www.lao.ca.gov 11 analysis full gutter 2020-21 BUDGET LAO PUBLICATIONS This report was prepared by Jason Constantouros, and reviewed by Jennifer Kuhn Pacella and Anthony Simbol. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 12 LEGISLATIVE ANALYST’S OFFICE