Texas has a large, growing population that is growing sicker and needs more and better-coordinated health care services. Unfortunately, Texas — even more than most of the rest of the country — needs more physicians and other health care professionals. Although our 2003 liability reforms have brought an influx of new physicians, the current supply won’t be able to keep up with the demand, especially with expanded insurance coverage from the Patient Protection and Affordable Care Act (PPACA). We need more physicians and other health care professionals working in all parts of the state, especially in rural and border Texas. We need to invest more in our medical schools and graduate medical education (GME) training programs. We should not fool ourselves into thinking that allied health professionals — who haven’t gone to medical school — can fill the gap as independent practitioners. Instead, we need to work on building physician-led health care teams that can safely meet the diverse needs of the Texas population.
Meet the growing demand for medically necessary care with clinically appropriate medical services
Texas State Data Center, March 2012
Texas’ population is expected to boom from 25 million to almost 45 million by 2040. These numbers include not just a larger population, but also a larger need for more health care services from a growing populace of increasingly obese Texans and the generally sicker elderly residents. 
Texas has long been challenged to produce or recruit enough physicians to keep up with our rapidly growing population. The sheer size of the state’s population is the biggest driver of physician demand. The state’s broad expanse and variance in geography and demographics, plus the great attraction for others to move to Texas, result in an ever-increasing demand for physicians and other health care professionals. Over the past two decades, Texas has led the country in population growth.
The convergence of a larger, increasingly aging, and increasingly obese population of Texans represents “a recipe for disaster.” In the United States, approximately 80 percent of all persons 65 or older have at least one chronic condition, and half have at least two. These patients take longer to treat and grow more and more complex in the amount of services and care they require. Diabetes, which causes excess morbidity and increased health care costs, affects more than 1.7 million Texans 65 or older. As U.S. adults live longer, the prevalence of Alzheimer’s disease, which doubles every five years after age 65, also is expected to increase. 
Texas is a state with significant shortages of physicians and other health care professionals. Several powerful trends are pushing those shortages to levels that will threaten the ability of Texans, regardless of where they live or whether they have insurance, to access health care. Those trends include:
- More than 5.7 million Texas baby boomers become eligible for Medicare,  the age group with the highest demand for physician services;
- Our high birth rate, which further increases demand for physician services;
- The possible addition, depending on the outcome of the November elections and the decisions of the Texas Legislature, of more than 2 million people eligible for Medicaid in 2014, due to the PPACA;
- The possible addition, depending on the elections and the legislature, of more than 2.2 million currently uninsured Texans who will qualify for subsidized coverage through the PPACA’s insurance exchanges; and
- The growing prevalence of chronic diseases that frequently require more health care services, such as diabetes and hypertension.
More and more Texans will experience health-related disparities because of poor health status and/or a lack of preventive health options or access to timely medical care. Health disparities include differences in the occurrence or prevalence of a disease or a poor health condition. For example, the Texas Diabetes Council estimates that the number of adult Texans with diabetes will quadruple from the current 1.7 million to almost 8 million in 2040. This surge is strongly associated with population growths in African-Americans and Latinos, who have higher rates of diabetes. 
People with diabetes and other chronic health conditions have complex care needs. Their physicians not only must treat the condition itself, but also must lead a team of caregivers who rally all the resources to help prevent costly complications for the patient.
Texas Diabetes Council, Fall 2010
Physicians must be the backbone of such a complex system of care if it is to be cost-effective. Otherwise, the state’s efforts to increase preventive care, improve medically necessary treatment for the chronically ill, and reduce inappropriate emergency department utilization will falter. Physicians also play an important role in helping develop and partnering with the public health system. This partnership can enhance local coordination of care, disease surveillance, access, and health promotion.
Make sure enough physicians and other health care professionals are working in all parts of Texas
Imagine life without access to a physician, for yourself, your aging parent, or your child. Without access to a physician, life-enhancing and lifesaving medical care is virtually impossible. Physicians are the nucleus of the formula needed to achieve the vision of the Texas Medical Association: To improve the health of all Texans. Access to health care depends on the availability of physicians with the skills to match the needs of the state’s population.
Texas has a shortage of both primary care physicians and other specialists. Texas ranks behind all the other most-populous states in the number of patient care physicians per capita. To evaluate this shortage across specialties, we have devised a metric that compares the number of Texas physicians per 100,000 population with the U.S. average. We call this the “Texas Specialty Ratio.” The closer this ratio is to 100 percent for a given specialty, the closer Texas is to the national average.
- Texas has fewer physicians per capita than the national average for 36 out of 40 medical specialty groups.
- Texas needs both more primary care physicians and other specialists. A number of specialties have acute shortages.
- Psychiatry and child/adolescent psychiatry are among the specialties with the lowest Texas Specialty Ratios.
We also must look to the Texas of tomorrow to evaluate the kinds of physicians we will need the most. Texas ranks fourth among the six most-populous states in medical students and resident physicians per capita. Texas continues to be overly dependent on other states and countries for supplying new physicians. Last year, nearly 75 percent of newly licensed physicians graduated from medical schools outside of Texas. We are thus subject to the vagaries of external forces that influence the numbers of physicians we can recruit. To meet future physician demands, Texas needs a stable, high-quality medical education system to produce homegrown physicians. Similarly, we must provide a reasonable opportunity for Texas medical school graduates to obtain their residency training in the state without being forced to leave home. Multiple studies confirm that physicians who complete both medical school and residency training in the state are three times more likely to practice here.
Because the human body is complex, the mastery of medical care is correspondingly complex, requiring a lengthy educational and training pipeline. Following college, physicians traditionally complete a four-year medical school education, followed by specialty training in residency programs for three to eight additional years, depending on the specialty.
The United States is in the midst of a medical education building campaign. Texas is among the leaders, with plans to increase enrollments to the nationally recommended 30-percent growth level by 2015. Texas is setting records in the number of medical school graduates, reaching 1,458 in 2011, a net gain of 80 (6 percent) from the preceding year.  The number of graduates is forecasted to peak at more than 1,700 this decade. 
Texas needs continued and stable state support for both critical parts of a physician’s education and training to help cultivate future generations of Texas physicians, ensuring stable access to health care for all Texans.
In 2011, almost half (48 percent) of Texas medical school graduates left the state for residency training. Texas invests almost $200,000 in a medical student’s four years of education. Texas physicians are concerned about the state’s ability to protect that growing investment with enough graduate medical education positions to meet demand. For 2011, the annual National Resident Matching Program offered 1,476 entry-level GME positions in Texas. By comparison, 1,445 students graduated from Texas medical schools in 2011.  The Texas Higher Education Coordinating Board recommends a ratio of 1.1 entry-level GME positions for each Texas medical school graduate. To meet this goal, Texas would have needed 1,590 entry-level training positions in 2011, or 114 additional positions.
Medical Education Is a Public Good and a Tremendous Economic Asset to the State
- Academic health centers generate an additional $1.30 in economic activity for every dollar spent. 
- Texas ranks fifth among states in the total economic impact of academic health centers. These centers serve as major employers in their communities and impact 210,000 jobs. Many of these are filled by highly educated and skilled workers at higher salary levels.
- Academic health centers have a major financial impact in every region they are located: Houston, Dallas, Bryan/College Station, Temple, Lubbock, El Paso, Fort Worth, and Tyler.
Texas medical school graduates are projected to peak at more than 1,700 around 2015.  This will mean an even greater demand for residency training positions to enable graduates to remain in the state. To achieve the 1.1-ratio goal after enrollments reach the peak, Texas would need to add an additional 400 GME positions. This growth will be even more difficult to achieve with the state legislature’s recent 41-percent reduction in overall state support for residency training.
Considering the significant challenges the state faces in meeting its health care workforce needs, state leaders must mandate a comprehensive health professions workforce analysis that includes all appropriate stakeholders and visualizes the needs of Texas for the near and long term.
Improve rural access to care
Physician shortages constitute a special problem in rural areas of the state. The continued urbanization of Texas exacerbates this longstanding problem. Approximately 12 percent of Texans live in rural counties,  yet only 10 percent of primary care physicians practice there.  In 2011, Texas had 52 primary care physicians per 100,000 population in rural areas versus 72 per 100,000 in urban areas.  Physician shortages in rural areas not only hinder access to primary and other specialty care but also lead to potential losses in the local economy, difficulties attracting new businesses, and diminished quality of life for residents. A number of factors hurt physicians’ ability to open and sustain rural practices, including heavy concentration of Medicare, Medicaid, and uninsured patients; professional isolation; and high debt after medical school.
Physician practices in rural Texas contribute to the local economy in three critical ways.
- They employ administrative and clinical staff to help care for patients. On average, a solo primary care physician in a rural area will employ three staff: a registered nurse, a medical technician or licensed vocational nurse, and a receptionist/billing clerk.
- They contribute revenue to and generate additional employment at local hospitals through inpatient admissions and outpatient services.
- They generate essential tax revenues for their communities.
If rural physician practices and rural economies are to thrive, physicians need incentives to practice in those areas. Medical school programs with rural-focused curricula increase the supply of primary care doctors in underserved areas as do loan forgiveness programs like the National Health Service Corps and the State Physician Education Loan Repayment Program (SPELRP).
No inappropriate scope of practice expansions
The state’s 11 health-related institutions have experienced firsthand the growing demand for health care services. They have expanded clinical services and added slots in their schools of medicine, dentistry, nursing, physician assistants, and a broad array of other health professions. Although the Texas Medical Board (TMB) has set a string of new records in medical license applications and newly licensed physicians since the passage of solid tort reform provisions in 2003, most other major health professions have grown at an even faster rate.
- Physician assistants and advanced practice nurses (APNs) grew at the highest rate, 132 percent and 1,114 percent, respectively. (Physicians grew by 32 percent.) In absolute numbers, registered nurses (RNs) had the largest gain, 56,000; physicians followed, up by about 10,000.
- While Texas added 56,000 RNs over the past decade, shortages persist in many parts of the state.
- Of the 10 largest health professions, podiatry had the slowest growth rate.
Texas Department of State Health Services, February 2012
This increase in the number of specially trained health care professionals is good for Texans. TMA believes that a physician-led team approach to care, with each member of the health care team providing care based on his or her education and training, is key to ensuring that patients receive high-quality care. Maintaining the integrity of the health care team, under the physician’s overall direction, is good for patient care. (TMA strongly supports physician-led teams using several health care professionals, each bringing important skill sets and training to patient care. Team care requires cooperation and collaboration among all professionals, with a focus on quality, measureable outcomes, and efficient utilization of resources. See Section 2 for more on this topic.)
This growth, along with the narrow political interests of a small number of allied health professionals, has spurred calls for Texas to grant them more independent practice. Such an expansion in their scope of practice not only would exacerbate Texas’ physician shortage, but also likely would increase costs and utilization, and could endanger the safety of our patients. The Texas Medical Practice Act was created more than 130 years ago to protect Texans from people who called themselves “doctor” but who did not have the skills, training, or education to warrant such a title. The act, administered by TMB, clearly defines the practice of medicine and the educational qualifications necessary to diagnose, independently prescribe, and direct patient care – and to be held accountable for that care.
In 2011, for example, APNs sought the independence to diagnose, prescribe, and order tests and treatments without physician collaboration. Two bills would have allowed APNs to practice medicine without the benefit of a medical education or passing exams that demonstrate medical knowledge and skills. Each would have the Texas Board of Nursing responsible for the regulation of APNs who would be practicing medicine.
The Texas Legislature, wisely, rejected those bills. Granting independent practice to APNs will not increase the health care workforce, nor has other states' experience shown APNs are likely to locate in medically underserved and rural areas. Further, APN independent practice will not lower costs. Research found utilization rates for medical services, referrals to specialists, and hospitalizations for patients were higher for APNs versus physicians or resident physicians.
On the other hand, some scope expansions are consistent with team care, based on objective educational standards, and would improve patient care services. These should be carefully weighed and ultimately involve some supervision and regulatory oversight by TMB.
- Preserve and protect state support for undergraduate medical education and the cultivation of the future generation of Texas physicians, thus ensuring stable access to health care for all Texans.
- Support and develop new graduate medical education programs in the specialties that best reflect the state’s health care needs. Support incentives for hospitals and other community-based agencies to develop residency programs in the specialties most needed.
- Direct the Texas Higher Education Coordinating Board to coordinate the availability of graduate medical education training positions so that Texas can retain our graduates for residency training.
- Sponsor research to identify and promote innovations in training primary care residents for practice in Texas, and to address the factors that influence why few U.S. medical school graduates select this training.
- Adjust the payment system for health care services to make primary care an attractive career option for those considering a rural practice.
- Reinstate the State Physician Education Loan Repayment Program funds that were slashed during the 2011 legislative session to encourage physicians to practice in rural and medically underserved communities.
- Strongly oppose any efforts to expand scope of practice beyond that safely permitted by nonphysician practitioners’ education, training, and skills.
- Support expansions of scope of practice laws that protect patient safety, are consistent with team care, are based on objective educational standards, and improve patient care services.
- Support legislation that strengthens the Texas Medical Board’s regulatory oversight of nonphysician licensees who, by specific educational achievement, are granted authority to perform acts traditionally reserved for and defined as the practice of medicine.
Healthy Vision 2020