Senate Committee on Finance
State Capitol Extension, Finance Room E1.036
Tuesday, Feb.10, 2009
Presented by Clifford Moy, MD
My name is Clifford Moy. I am a psychiatrist by training from Austin. I would like to thank the chair and members of the committee for the opportunity to testify today.
As an organization that represents nearly 44,000 physicians and medical students, we hold care for our patients as our first priority. With that in mind, I feel compelled to share with you today the critical concerns physicians have about the future of patient care in Texas. Before we can discuss a solution, however, I first need to describe the current problem.
Texas has a shortage of physicians. We have shortages in primary care as well as shortages in some specialty areas. We need more geriatricians to treat our seniors, more pediatric specialists to treat our sickest children, more endocrinologists to treat diabetes, more surgeons and emergency room physicians at our hospitals, more dermatologists to detect skin cancer, and more adult and child psychiatrists to treat mental health needs, to name only a few.
Texas ranks 42nd among 50 states and the District of Columbia in the ratio of physicians to population. We fall below not just small states but large ones as well. Texas ranks behind California, New York, Florida, Pennsylvania, and Illinois the most populous states in the country - which receive more federal graduate medical education, or GME, funding than Texas.
To address this problem, national leaders in workforce planning are calling for significant increases in new physicians, recommending a 30-percent increase in medical school enrollments and a 15-percent increase in GME slots. After 20 years of flat growth in medical school enrollments, the state has some catching up to do.
Texas medical schools have responded with plans to increase enrollments 30 percent by 2015. However, medical student per-capita formula funding now stands below funding levels for the years 2000 through 2003. When inflationary factors are considered, the funding gap from 2000 grows even wider. There is a need to restore over, the next two biennia, the base value for the instruction and operations support formula for medical education to the levels in 2000-01, as recommended by the Texas Higher Education Coordinating Board.
If, however, we do not expand GME at the same time that medical school enrollments are increased, we will do little to produce more homegrown physicians for Texas. Texas has fewer GME slots than California, New York, or even Pennsylvania.
Currently, to practice medicine in the United States, a physician must complete a GME, or residency, program. It is the portal for practicing in the United States. Thus, the availability of GME drives the size of the physician workforce. A physician can no longer go directly from medical school into the practice of medicine.
I'm sure you agree it is not good fiscal policy to make a state commitment of $50,000 a year for each Texas medical student for four years, then after students graduate from medical school, force them to leave the state for GME. This happens every year because we do not have enough GME slots. In 2004, Texas lost $27.4 million educating medical students who left the state for GME (most recent year available). These students wanted to stay in Texas but due to the shortage of GME slots, they had to leave.
Our legislature, including many of you, took a strong position in support of GME expansions in 2007 through increased GME formula funding. However, the job is not done. The largest share of GME funds comes through Medicare, which capped the number of GME-funded slots at the 1996 level. That means there have been no new Medicare-funded GME slots for 11 years.
There is a need to align the state's GME capacity with the state's physician workforce needs. The amount of state GME formula funding available this biennium is extremely helpful; however, at $5,634 a year for faculty educational costs, it represents less than one-third of the $16,000 in estimated faculty costs per resident for GME in Texas. It has been estimated that the total cost of educating a resident physician, including both medical school and teaching hospital costs, is approximately $100,000 a year.
Nevertheless, new GME slots have been created in the state through your efforts and have been filled. It is important to continue to fund the residents in the new positions for the duration of their training.
Primarily due to the state's stabilized professional liability environment, Texas has been able to attract record-high numbers of new physicians - more than 14,000 physicians since 2003, as reported by the Texas Medical Board. In comparison with the state's growing health care needs, this raises the question of whether the growth has been enough.
You know well that Texas has been leading the nation in population growth and that our population is aging. From 2000 to 2008, the Texas physician supply grew 21 percent. At the same time, however, the number of Texans grew 19 percent, which indicates we are barely treading water.
When we project forward to 2015, the forecasts are even more troubling, with population expected to grow faster than our physician supply. This indicates that we likely have not done enough.
We need to:
- Expand our medical school enrollments,
- Expand GME commensurate to medical school enrollments,
- Maintain a stable practice environment so we can continue to recruit new physicians and retain those we have, and
- Provide an adequate amount of loan repayment dollars to allow medically underserved communities to more effectively recruit new physicians. Many physicians are now leaving their training programs with debt more than $200,000, yet some funds in the state loan repayment program went unspent in the past year. Texas doctors are recommending a proposal similar to what the legislature approved for the Medicaid Frew vs. Hawkins lawsuit settlement, where total repayment dollars are increased over the recent $45,000, established in the mid-1980s, to bring this program up to date.
Further, programs such as the Texas Statewide Primary Care Preceptorship Program, administered by the Texas Higher Education Coordinating Board, have been important tools for fostering interest in primary care among our medical students. The coordinating board's program provides an opportunity for medical students to shadow a primary care physician for four weeks to learn firsthand about primary care. One-half of the program's $2 million biennial budget was cut in 2004 as a cost-saving measure. It is important to restore state support for primary care preceptorships, especially in light of the state's growing demand for primary care physicians.
In closing, I also would like to emphasize that physicians recognize that health care is best delivered as a team. We are concerned about the shortage of bedside nurses, nursing faculty, and some other allied health professions. The legislature has worked hard to address Texas' health care workforce shortages in recent sessions. We encourage you to continue to do so, and consider these actions:
- Recruit more physicians and bedside nurses for high-quality patient care,
- Sustain medical school enrollment growth and GME with adequate per-capita formula funding ($16,000 per resident) and restoration of Medicaid GME funding,
- Restore state per-capita medical student formula funding to 2000-01 levels over the next two biennia,
- Restore funding to the Texas Statewide Primary Care Preceptorship Program,
- Impact geographic maldistribution through meaningful loan repayment amounts well above the recent total of $45,000 in repayment dollars, and
- Maintain a stable practice environment for Texas physicians.
Thank you for the opportunity to provide testimony today.