REPORT OF COUNCIL ON MEDICAL EDUCATION
CME Report 5-A-07
Subject: Growth in Medical School Enrollments and Graduate Medical Education Programs, and Expansion of State Physician Education Loan Repayment Program
Presented by: Dennis B. Dove, MD, Chair
Referred to: Reference Committee on Science and Education
The Council on Medical Education evaluated three workforce-related recommendations presented in "Code Red-the Health of Texas" for possible adoption as TMA policy and found sufficient cause for doing so. Code Red was issued by the Task Force on Access to Health Care in Texas in April 2006 with a focus on methods for improving access to care for uninsured, indigent patients. Because each of the three recommendations touch on an aspect of physician workforce planning, the council sought technical assistance from the Committee on Physician Distribution and Health Care Access, the committee charged with monitoring physician workforce trends. The committee's response was to conduct a trend analysis focused on medical school enrollments, graduate medical education, state physician workforce needs, and projected population growth. The committee's process, findings, and recommendations are attached ( Attachment A ).
Of particular interest to the committee was an assessment of how much Texas medical schools could reasonably expand medical school enrollments to better address the state's continuing physician shortage. Through a review of medical school enrollment statistics, the committee learned that the entry-level class-size increased by 9.2 percent (122 students) from academic years 2004/05 to 2006/07. Further, by surveying Texas medical schools in November 2006, it also was learned that the schools have a projected growth rate of 24.7 percent (329 students) from 2004/05 to 2010/11, and 30.7 percent (408 students) from 2004/05 to 2015/16. Both actual and projected enrollments are presented in Attachment A-1 .
Based on the committee's trend analysis, as described above and in the attachments, as well as supporting facts presented by the task force in the Code Red report, both the committee and council felt compelled to recommend the adoption of all three Code Red workforce-related recommendations as TMA policy and recommend adoption of the following:
Recommendation: The Texas Medical Association supports the three workforce-related recommendations presented by the Task Force on Access to Health Care in Texas in "Code Red-the Health of Texas, April 2006":
1. Texas should increase the number of physicians annually graduating from its medical schools by 20 percent over the next decade with special emphasis upon creating a workforce representative of the state population.
The Texas Medical Association recognizes the recommendation for a 20 percent increase in medical school enrollments over the next decade to be feasible and desirable for the state based on an analysis of trends in medical school enrollments (actual and projected), graduate medical education programs, and the state's physician workforce needs. The recommended growth rate should be periodically assessed for relevancy. The Texas Medical Association believes it is prudent not to recommend an increase that carries a high risk of diminishing the quality of students accepted into Texas medical schools. Based on recent and projected medical school growth, as well as the anticipated applicant pool, it appears Texas medical schools could reasonably grow at least 20 percent by 2010 while maintaining the quality of the applicant pool. Should the applicant pool become diminished, a greater effort should be made to recruit high-quality students. Further, there is a need for growth in entry-level graduate medical education positions in the state commensurate with medical school enrollment expansions.
2. Texas should expand medical school loan repayment programs for graduates of Texas medical schools working in Texas to include up to 500 physicians per year. One-third of student debt up to $35,000 per year should be forgiven for each year of service in a public hospital or in a clinic in which the patient population equals or exceeds 50 percent Medicaid and uninsured patients
The Texas Medical Association endorses the concept of the recommendation with the goal of providing $35,000 in loan repayment each year to 500 physicians who agree to practice at a public hospital or health clinic with at least 50 percent patient population enrolled in Medicaid or determined to be indigent. It is further recognized that the existing state physician education loan repayment program also should continue to provide loan repayment to physicians who practice in medically underserved areas of the state, including rural communities.
3. State support of medical residency programs should allow an increase in residency positions by 600 per biennium for the next decade.
The Texas Medical Association supports the call for increases in graduate medical education positions and the need to provide direct funding to residency programs. To prevent the loss of medical graduates from the state as Texas medical school enrollments increase, there is the need for concomitant growth in graduate medical education training slots sufficient to allow for the retention of medical school graduates and a reasonable overage to allow other graduates to train in Texas. Workforce trends should be monitored on a continuing basis and periodically used to reassess needed growth in graduate medical education slots in the state.
ATTACHMENT A
Report from Physician Distribution and Health Care Access Committee to Council on Medical Education
Feb. 7, 2007
Council on Medical Education Request for Technical Assistance on Possible Adoption of Code Red Policy Recommendations
In response to the council's request for technical assistance on the appropriateness of adopting three workforce-related policy recommendations put forward in the Code Red report as TMA policy, these items were placed on the committee's agenda for discussion and action at the February 2 meeting. Based on the committee's deliberations and the data analysis provided in this report, the committee voted to endorse all three Code Red recommendations and to forward its endorsement to the council for consideration.
The three policy items and the committee's recommended action for each are summarized below:
Code RedPolicy
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PDHCA Committee Recommendation:
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1. Texas should increase the number of physicians annually graduating from its medical schools by 20 percent over the next decade with special emphasis on creating a workforce representative of the state population.
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2. Texas should expand medical school loan repayment programs for graduates of Texasmedical schools working in Texasto include up to 500 physicians per year. One-third of student debt upto $35,000 per year should be forgiven for each year of service in a public hospital or in a clinic in which the patient population equals or exceeds 50 percent Medicaid and uninsured patients.
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2. TMA endorses the concept of the recommendation in the Code Red Report that seeks a state physician education loan repayment program with the goal of providing $35,000 in loan repayment each year to 500 physicians who agree to practice at a public hospital or health clinic with at least 50 percent patient population enrolled in Medicaid or determined to be indigent.
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3. State support of medical residency programs should allow an increase in residency positions by 600 per biennium for the next decade.
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3. TMA further supports the call for increases in GME positions outlined in the Code Red report and the channeling of additional state GME funding for residency slots in community-based ambulatory programs. To prevent the loss of medical graduates from the state as Texas medical school enrollments increase, there is the need for concomitant growth in GME training slots sufficient to allow for the retention of medical school graduates and a reasonable overage to allow other graduates to train in Texas.
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TREND ANALYSIS
Current policy recommendations for growth in medical school enrollments range from 15 to 30 percent, two on the national level and one for the state, including the following:
Related Policy Recommendations
- Council on Graduate Medical Education's 15 percent growth recommendation {growth to occur from 2002 over next decade (by 2012), on the national level}. [1]
- Code Red's 20 percent recommendation over next decade on state level (by 2016); and
- Association of American Medical Colleges' call for 30 percent more by 2015 on the national level [2] .
To help define a state growth target, TMA was charged by the medical schools at the TMA Medical Education Summit held Oct. 23, 2006, with surveying individual medical schools and working with the Texas Centralized Medical and Dental School Application Service to assess estimated capacity for growth, in the context of expected patient caseloads, available faculty, training sites, accreditation requirements, and a high-quality applicant pool. TMA responded by conducting the survey in late 2006. The results of the survey are summarized below along with statistics on actual increases in medical school enrollment and population projections. More detail is provided in Attachment A-1 .
MedicalSchoolEnrollments
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Percent Increase
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Increase in Class-Size
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Actual Increase in Medical School Entry-Level Class-Size
From 2004/05 to 2006/07 Academic Years.
{Note: 2004 was chosen as base year because this is the year Texas enrollments began to rise.}
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9.2%
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122 students
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Projected Growth Rate 2004/05 to 2010/11
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24.7%
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329 students
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Projected Growth Rate 2004/05 to 2015/16
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30.7%
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408 students
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Population Growth
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Projected Total TexasPopulation Increase
from 2005 to 2010:
from 2005 to 2015:
from 2005 to 2020 : Source : Texas State DataC enter, October 2006, Steve Murdock, PhD, State Demographer.
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8.96%
17.1%
24.4%
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COMPARISON: Based on projected growth rates reported by Texasmedical schools, medical school enrollment growth could exceed projected population growth for the time period 2004/05 to 2010/11 and 2004/05 to 2015/16.
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Six of eight medical schools said in the TMA survey that they could accept more students. The schools also were asked to assess how deep they could reach into the applicant pool and still be able to maintain the same quality of applicant as those recently admitted to medical school. In response, 67 percent of schools (4 of 6) that reported they could accept more students said they could accept an additional 20 percent of applicants and still maintain the same quality applicant as recent matriculants. Of these four schools, two said they could even accept 30 percent under these criteria. Two of the six schools said they could not accept 20 or 30 percent more at the same quality level but on average could accept 8.2 percent more (ranging from 4.5 to 10 percent). [3]
Based on the actual growth in medical school enrollments since 2004 and the projected growth reported in the TMA survey, the committee determined Texas medical schools could reasonably be expected to grow at least 20 percent by 2010. This finding applied both in terms of having the resources to expand class-sizes as well as the depth of the applicant pool (as an indicator of the potential for maintaining high-quality matriculants in the near future). The committee felt the second consideration was as important as the first and did not feel it would be prudent to recommend an increase that carried a high risk of diminishing the quality of medical school matriculants. Based on these assessments, the committee feels it is reasonable to endorse recommendation 1 from the Code Red report calling for a target growth of at least 20 percent over the next decade.
Recommendation 2, Expanded State Physician Education Loan Repayment Program
The Code Red recommendation calls for an increased annual repayment amount from the current $9,000 to $35,000 for 500 physicians a year. The current program provides loan repayment to about 72 physicians each year. The committee recognizes that the current program has been successful in attracting physicians to underserved areas but funding constraints allow only a relatively small number of physicians to benefit. It is also recognized that education-related debt is rising for physicians, bringing with it the need for higher levels of loan repayment. The Code Red recommendation seeks to address the need to provide increased access to care for Medicaid and uninsured patients.
Recommendation 3, Increase in Graduate Medical Education Slots of 600 Per Biennium for Next Decade
There is a slim margin between the number of Texas medical school graduates and the number of entry-level graduate medical education positions in the state. The shortage causes an expected loss of graduates from Texas to other states due to the lack of training positions. The recent 9.2 percent increase in medical school enrollments and projected additional class-size growth is expected to further exacerbate the shortage of entry-level GME positions.
Accordingly, there is a need to grow Texas residency programs. Further, in recognition of the growing trend toward the movement of residency training outside the hospital setting, the committee feels GME funding should be directed towards residency programs rather than teaching hospitals in order to support community-based, ambulatory training sites. The committee believes workforce trends should be monitored on a continuing basis and periodically used to reassess needed growth in GME slots in the state in the near future.
[1] "Physician Workforce Policy Guidelines for the U.S., 2000-2020," 16th Report, Council on Graduate Medical Education, January 2005. Note: This council is the federally designated advisory body to Congress on graduate medical education and medical education issues.
[2] In 2002, there were 16,488 new matriculants in allopathic medical schools. A 30 percent increase is equal to an additional 4,946 matriculants per year. This would require 21,434 new matriculants in 2015.
[3] In addition, The University of Texas Health Science Center at San Antonio reported a lack of resources to expand enrollments but should resources become available, the applicant pool was or is expected to be sufficient to allow an additional 10 percent of applicants to be admitted who are comparable to recent matriculants.
TMA House of Delegates: TexMed 2007