Why Texas Needs More Physicians

 

 

 

 

Overview

Texas needs more physicians . Why? The state does not have enough physicians to keep up with the growing demand. More are needed because:

  • Texas is growing at a fast and consistent rate, both through new births and through in-migration;
  • Texans are living longer, and, as people age they require more physician services;
  • More specialty care is now available;
  • Texans of all ages are seeking more physician services;
  • Texas' vast expanses of rural and border areas have long-standing physician shortages;
  • The increasing prevalence of health conditions such as obesity require more health care; and
  • A regular succession of groundbreaking innovations in medical science is resulting in a proliferation of new treatments and services.

The growing need for physicians in Texas is part of a national trend.  This state, however, is at a clear disadvantage in its capacity to grow its own workforce.  Texas medical schools are heeding the call to expand enrollments, growing by 2 percent this year and marking further plans to produce more physicians.  Further expansions, however are stymied by serious limitations in educational infrastructure and funding. This leaves Texas in the vulnerable position of depending on other states and countries to produce the physicians we need.

Texas has about 43,000 physicians engaged in patient care for a population of about 23 million.  The most recent reports show Texas ranking 45 th in the nation in the number of physicians per population . Its eight medical schools and their partner organizations educate and train about 5,400 medical students and 6,000 resident physicians, numbers that have changed very little in about 25 years. The lack of growth is a result of a combination of factors:

  • Predictions of an oversupply of physicians by the year 2000 that proved to be grossly inaccurate;
  • A ratcheting-down of federal graduate medical education (GME) support. Most damaging of all, the ongoing freeze of Medicare's funding of GME at 1996 levels combined with a whittling away of federal GME support through the Title VII primary care and children's hospital GME programs;
  • Reoccurring cuts in the state funding of medical schools and graduate medical education, including the loss of an estimated $127 million in Medicaid GME support (including federal match dollars) and $8 million in other GME funds. Texas is now one of only three states that does  not pay for GME through the state Medicaid program ; and
  • Shrinking operating margins at teaching hospitals that not only jeopardize the future of existing residency programs but also preempt needed growth opportunities.

The lack of funding for medical students and GME puts Texas at a distinct disadvantage in growing its own physician supply.

Texas ranks 2 nd in total population.  When compared with the top six most populous states, Texas falls to 4 th in the ranking of both the number of medical students and the number of physicians in training (resident physicians) per capita. New York leaves Texas far behind in both rankings by an extraordinarily wide margin , as shown in the  table below . Other high-population states have been successful in educating or recruiting more physicians than Texas, leaving Texas at the bottom in the number of physicians per capita for high-population states. 

Six Most-Populous  States  and U.S.  Comparisons

Texas

California

Florida

Illinois

New York

Penn.

U.S.

Total

               

Population

22,859,968

36,132,147

17,789,864

12,763,371

19,254,630

12,429,616

296,410,404

Medical Education

# Medical Schools (MD/DO)

7/1

8/2

4/2

7/1

12/1

6/2

125/21

Total # Medical Students

5,419

5,591

2,578

5,238

8,148

6,307

80,200

Med Students per 100,000 Pop.

24 (4)

15 (5)

14 (6)

41 (3)

42 (2)

51 (1)

27

Total # Medical Grads

1,258

1,293

522

1,228

1,997

1,471

18,449

Medical Grads per 100,000 Pop.

5.5 (4)

3.6 (5)

2.9 (6)

9.6 (3)

10.4 (2)

11.8 (1)

6.2

GME

# Residency Programs (MD/DO)

488/18

714/21

257/42

403/37

1,083/53

553/103

8,264/591

Total # Resident Physicians

6,467

9,084

3,207

5,693

15,525

7,397

103,874

Resident Physicians Per 100,000 Pop.

28 (4)

25 (5)

18 (6)

45 (3)

81 (1)

60 (2)

35

Physician Supply

Total Patient Care Physicians

42,506

82,143

38,675

30,696

63,517

31,741

698,995

Patient Care Physicians per 100,000 Pop. [i]

186 (6)

227 (4)

217 (5)

241 (3)

330 (1)

255 (2)

236

The average age of a Texas physician in 2005 was 48.4 years.  About 3,200 physicians (8.8%) are 65 years of age or older and are likely to retire in the near future.  In comparison, Texas graduated 1,260 medical students last year, less than 2.5 times the number of Texas physicians that could retire. Texas is not producing enough physicians to keep up with demand.  

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Medical Education Funding

State support for medical education has been unstable in recent years and is not sufficient to produce the number of needed physicians. Instead of funding to allow for growth, current funding stands 7.2 percent below the 2002-2003 level.        

State Biennial Budget State Base Funding Per Medical Student Difference from 2002-2003 Funding Level
2002-2003

$56,000

-

2004-2005

$47,216

-19%

2006-2007

$52,221

-7.2%

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Graduate Medical Education (GME) 

GME refers to the specialized training a physician receives after graduating from medical school. Texas law requires a U.S. medical graduate to complete one year of GME training to qualify for a medical license. However, it is common practice for physicians to seek national board certification in their individual specialty. This requires completion of an entire residency training program, ranging from a minimum of three to as many as nine years of training. Board certification is also a common requirement for participation in health plan networks and for securing hospital-admitting privileges.

Specialty training is obtained through completion of a residency program in a specific field of medicine or medical specialty such as neurology or emergency medicine.  Residency programs are accredited by national organizations, and the overwhelming majority is sponsored by medical schools. Training occurs in a variety of settings influenced by the field of study. For example, specialties such as surgery, radiology, pathology, and emergency medicine are typically hospital-based, while specialties focused on ambulatory care, such as family medicine and pediatrics, are more likely to have training in community-based clinics or doctor's offices. 

It is commonly recognized that physicians tend to enter practice in an area close to their GME program. TMA studies show that physicians who complete both medical school and GME in the state are almost three times more likely to practice in Texas . Similar findings have been reported by The University of Texas System. 

GME programs provide large amounts of indigent care.  The relatively low salaries of residents (generally, less than $40,000 a year) help residency programs afford to care for large numbers of indigent patients.

In addition to high levels of indigent care, residency programs in underserved areas of the state have demonstrated their ability to produce physicians that choose to remain in needy areas of the state. Incentives such as the state physician education loan repayment program administered by the Texas Higher Education Coordinating Board have become even more valuable to underserved communities as physicians have experienced soaring education-related debt (averaging $120,000 per student; Association of American Medical Colleges, 2005 Survey). This successful program could serve even more underserved communities with additional state funding.     

Texas medical schools and teaching hospitals produced a combined total economic impact of $19.6 billion in 2002, the most recent year available. Of this, $8.5 billion had a direct impact and $11.1 billion was indirect.  Texas ranked fifth in the nation, followed by states such as New York, Pennsylvania, California, and Massachusetts, in overall economic impact. Medical schools and teaching hospitals are major employers and recipients of spending by hospital patients, patients' visitors, students, and their visitors.  They also bring in governmental and private research dollars. The economic "multiplier effect" averages 2.3 for teaching hospitals; meaning for every dollar spent, an additional $1.30 is generated, for a total economic impact of $2.30.

With 6,386 GME slots, Texas has fewer than New York (15,084), California (8,924) or Pennsylvania (6,828). California and New York have been successful in securing non-governmental funding for GME. An all-payer system in New York and an extraordinarily high level of Medicare GME base-funding help support a disproportionately large GME system in that state. Further, California has been able to benefit from contributions to GME funding by some large managed care organizations such as Kaiser Permanente.

The GME shortage in Texas raises a multitude of concerns:

  • A GME shortage virtually guarantees some medical students will be forced to leave the state upon graduation. Given the strong relationship between location of GME training and entrance into practice, it is likely those leaving will not return to Texas, taking with them at least $200,000 the state invested in their medical school education;
  • Recent joint TMA/medical school surveys of residents leaving the state for GME found that 137 (38 percent) would have preferred to stay in Texas for GME, representing a combined loss of $27.4 million to the state from the investment in their medical education; 
  • Texas medical graduates are denied the opportunity to train in their own state;
  • Texas lacks resources to train an adequate number of physicians as well as the needed types of specialists for its own workforce. This places us in the vulnerable position of depending on other states and countries to produce the physicians Texans need .

Additional GME slots are needed:

  • To provide the opportunity for a return on the state's substantial financial investment in medical students;
  • To provide better educational opportunity for Texans; and
  • To train the number of physicians needed to meet the state's health care needs and prevent an overdependence on other states and countries.   

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Unstable State GME Funding

GME funding at the state level has been unstable and inadequate in recent years.  Not only has new funding not been available to allow for growth in response to rising state demand, GME programs have lost ground through repeated funding cuts. As noted previously, Texas is one of only three states in the country that does  not provide GME funding through the state Medicaid program.

Current state funding for GME is now 60 percent less than it was four years ago, as shown in the following table.

 

        % Change % Change
State Programs 2002-03 Funding 2004-05 Funding 2006-07 Funding

2004-05 vs. 2002-03

2006-07 vs. 2002-03

State GME Funding Allocated by Higher Education Coordinating Board : Primary Care GME Programs

$43,660,569

$27,464,848

$26,091,554

-37%

-40%

Formula Funding (Established 2006-07 via Appropriations Rider)

-0-

-0-

25,000,000

-

+100%

Special Item Funding to Medical Schools

9,465,917

8,048,153

24,400,000

-15%

+158%

GME Funding to Teaching Hospitals :          
Resident Physician Compensation Program

8,070,238

-0-

-0-

-100%

-100%

Medicaid GME Payments

E 126,800,000

E 7,200,000

-0-

-94%

-100%

Total: GME Programs Note: E=estimated

E 187,996,724

E 42,713,001

$75,491,554

E-77%

E-60%

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Summary

  • The state's growing population, increased longevity of its residents, vast expanses of rural and border areas, growing prevalence of chronic diseases, greater availability of specialty services and breakthroughs in medical science are all contributing to an accelerating demand for physicians.
  • Predicted physician oversupplies were inaccurate, and the state is facing shortages in a number of medical specialties.
  • Texas medical schools are not producing enough physicians to replace those eligible to retire; 3,200 physicians over age 65 compared with 1,260 medical graduates in 2005.
  • Reoccurring rounds of cuts in federal and state funding of medical education and GME are preventing the state from training sufficient numbers to keep up with demand, including the major loss of an estimated $127 million in Medicaid GME funding.
  • Teaching hospitals have a substantial economic impact on local and state economies, averaging an economic multiplier effect of 2.3; for every dollar spent, an additional $1.30 is generated.
  • GME programs are leading providers of indigent care; an important contribution in a state with an uninsured rate of 25 percent - the highest in the nation.
  • Texas needs adequate state funding to sustain and grow medical schools and GME programs.
  • Without increases, Texas will not produce enough physicians to meet the state's growing demand; will not provide adequate opportunity to Texas medical graduates to train in the state; and will put the state in a vulnerable dependency role on other states and countries to prepare Texas' future physician workforce.
  • Texas must build an adequate homegrown supply of appropriately trained physicians.

Recommendations: 

  • Fund the newly established state formulas for GME at adequate levels.
  • Reinvest state funds in Medicaid GME and restore ability to draw down additional federal matching dollars.
  • Produce more homegrown physicians through adequate funding of medical school expansions.
  • Expand the State Physician Education Loan Repayment Program to recruit and retain more physicians in underserved areas.
  • Provide adequate funding for the Texas Medical Board to allow increased numbers of physicians to receive state medical licenses in an expeditious manner.

Staff at TMA would be pleased to respond to questions or provide additional information on medical education and GME.  Thank you for the opportunity to provide input on these important topics .

 

 

[i]

Note :  Rows do not add across; the last column is a total for all states including states shown in the table. 

Sources : Allopathic (MD) Medical Education:  Medical school enrollments for academic year 2005/06 extracted from Association of American Medical Colleges

Allopathic (DO) Residency Data:  Journal of American Medical Association, Sept. 7, 2005; Vol. 294, No. 9; Data are for academic year 2003/04.

Osteopathic Medical Education : Enrollments for 2004 extracted from American Association of Colleges of Osteopathic Medicine, 2004 Annual Report.

Osteopathic Residency Data : Tabulated from American Osteopathic Association Web site for academic year 2005/06.

State and U.S. Population :  U.S. Census Bureau, July 1, 2005 Population Estimates.

Physician Supply :  "2004 American Medical Association Physician Characteristics and Distribution in the U.S."

Prepared by : Medical Education Department, Texas Medical Association; 1/06.

     

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