The Texas Physician Workforce: Current Status and Future Direction
The Journal - November 2009
Tex Med. 2009;105(11):e1.
By T. Samuel Shomaker, MD, JD
Send correspondence to T. Samuel Shomaker, MD, JD, Professor and Dean, The University of Texas Medical Branch Austin Program, University Medical Center at Brackenridge, 601 E 15th St, Suite 3.117, Austin, TX 78701; e-mail: firstname.lastname@example.org .
The United States is facing serious physician workforce challenges. These include a shortage of physicians; declining interest in primary care; a maldistribution of doctors, particularly in inner-city and rural areas; the lack of a coherent workforce planning mechanism; and a workforce that does not reflect the diversity of the general population. Texas has many of the same issues, but problems are magnified by a historically low physician-to-population ratio; a rapidly growing and increasingly diverse population; and significant access-to-care issues, driven by a large uninsured population. This article reviews the current status of the US physician workforce and the challenges facing the nation over the next 20 years, and compares the national situation with prevailing and future conditions in Texas. Unless current trends are altered, Texas will face a growing shortage of physicians (particularly in primary care and certain specialty areas) that will be worse in rural and border areas. Although Texas medical schools are increasing enrollment, the growth in their graduate medical education slots is not keeping pace, creating a bottleneck that will constrain growth in the number of practicing physicians.
US Physician Workforce: A Short History
Only a few years ago, experts and national medical organizations were predicting a significant oversupply of doctors in our country.1-3 Now the opposite is true; many of the same experts and groups are warning that we are facing a serious shortfall of doctors, which will worsen significantly through 2020.4-6 This article reviews the status of the physician workforce in Texas and assesses how trends in Texas compare with what is happen in the United States overall. It updates previous work on the Texas physician workforce published by Guckian et al7 from 1995 and Kennedy and Spears8 from 1994.
The debate on the physician workforce dates back to the Flexner Report of 1910. Flexner decried the existence of unregulated, proprietary medical schools that produced poorly trained, substandard physicians. The report led to the closing of many of these schools, resulting in a decrease in the supply of physicians.9 By 1930, the physician-to-population ratio in the United States had fallen to 125 per 100,000, from its 1900 level of 173 per 100,000. The supply of doctors grew roughly in parallel with the population from 1930 to 1960, reaching 140 per 100,000.10
In 1959, a national report predicted a shortfall of 40,000 physicians by 1975.11 This report led to federal legislation subsidizing the expansion of medical education so that, by 1980, the number of medical schools had increased from 88 to 126 and annual graduates, from 7,400 to more than 15,000.9,12
In 1965, the federal government began funding graduate medical education (GME) through Medicare.13 The legislative language stated, "Educational activities enhance the quality of care in an institution, and it is intended, until the community undertakes to bear such educational costs in some other way, that part of the net cost of such activities (including stipends of trainees, as well as compensation of teachers and other costs) should be borne to an appropriate extent by the (Medicare) hospital insurance program."14,15 Total federal Direct GME (DME) payments peaked at $2.9 billion in 1996 and now total $2.5 billion (about 0.5% of federal health care expenditures).16
By 1980, the need for some type of national physician workforce planning led to creation of the Graduate Medical Education National Advisory Committee (GMENAC). Using more-or-less scientific techniques of forecasting supply and demand, GMENAC issued a report predicting that the United States would have a doctor surplus of 145,000 by the year 2000.17 On the basis of this report, Congress discontinued federal support for medical student education - support that has never been restored. 18
In 1982, Congress created special additional Medicare payments for GME as adjustments to the diagnosis-related group (DRG) payments that teaching hospitals receive for clinical care. These so-called Indirect GME (IME) payments were based on a hospital's resident-to-bed ratio and were intended to cover additional, but difficult to quantify, GME program costs (eg, highly specialized services, research, and the teaching of residents). These payments to teaching hospitals now amount to around $5 billion annually.13,16
In 1986, Congress created the Council on Graduate Medical Education (COGME) to provide advice on workforce issues.18 In a series of reports,1,19,20 COGME agreed with GMENAC's earlier prediction of an impending oversupply of physicians, predicting a surplus of 80,000 by 2000. At the same time, COGME noted a shortage of primary care doctors and recommended that the overall number of US GME slots be capped at 110% of the number of US medical graduates and that 50% of those positions be in the primary care disciplines (the so-called 110/50/50 rule). Building upon this recommendation, a group of national organizations including the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) issued a consensus statement in 1996 forecasting a physician surplus and calling on Congress to reduce the number of federally funded GME slots as a means of limiting workforce growth.21,22 Congress responded by passing the Balanced Budget Act of 1996, capping the number of federally funded residency slots at 1996 levels.16
During the years between 1980 and 2005, the number of medical students graduating from US medical schools remained flat at about 15,000, and no new medical schools were established. This led to a drop in the number of medical school seats per capita.23 Despite the cap on Medicare reimbursement for new GME positions, the number of first-year residency positions grew slowly over this period to about 25,000.16 This gap between US graduates and the number of first-year residency slots led to the growth in the number of international medical graduates (IMGs). By the late 1990s, IMGs occupied roughly 25% of the first-year residency positions in the United States.24
As the year 2000 came and went, the consensus that the country was facing a physician surplus was called into question. In 2002, Richard Cooper et al wrote an article based on his model that links demand for health services to the growth of the gross domestic product, stating that the United States had a shortage of physicians that would grow to 50,000 by 2010 and to 200,000 by 2020.4 The notion of an existing and impending physician shortage has been echoed by many recent reports and articles.25-31 Although skeptics still believe that the perceived shortage is more imagined than real, 32-34 the consensus now seems to be that the country will experience a shortage of physicians for at least the next 15 years ( Figure 1 ) [ PDF ]. 23,25 This shortage will be worse in some specialty areas (eg, the primary care disciplines) and in some areas of the country (especially those experiencing rapid population growth, such as Texas).6,18
On the basis of this body of evidence, AAMC challenged the medical education community to increase medical school enrollment by 30% by 2015.35 The response has been growth in medical education programs unseen since the 1970s. Many existing medical schools, including those in Texas, have expanded class sizes, and a number of new medical schools have been established or are in the planning stages.36 In Texas, the Paul L. Foster School of Medicine at Texas Tech El Paso became the first new medical school established in Texas since the founding of Texas A&M College of Medicine in 1977. Several other schools have established or expanded regional campuses, including Texas A&M (College Station, Temple, and Round Rock), UT San Antonio (Regional Academic Health Campus in Harlingen and Edinburg), and UTMB (Austin).36
Why the volatility in predictions concerning the physician workforce? Predicting the need for physicians is a complex exercise that involves balancing supply and demand.5,6,18,37 The supply side is relatively straightforward. The common pathway to obtaining a license to practice medicine is residency training. Thus, supply is the number of residency graduates minus those leaving the workforce for any reason. An adjustment is also necessary for those working clinically less than full time. Demand is far more complex, involving two basic approaches. 38 One assumes that current patterns of utilization of health care services will continue and projects them forward to create a basis for calculating demand. Most national reports are organized around this approach.4-6 The second approach asks how many physicians would be needed to care for our population in an ideally organized health care system.33,39 For example, a staffing pattern of a vertically integrated health system is often used as a benchmark.
In either approach, a large number of demand-side variables must be accounted for. Clearly, the US population is growing and aging, and both of these factors increase demand for health care services. The population will grow by 50 million between 2000 and 2020.5 In addition, the population older than 65 years will increase from 35 million in 2000 to 54 million in 2020. 5 Although we are living healthier and longer, an older population has more chronic diseases and uses more health care services.23
Economic growth also tends to increase demand.40 As Cooper describes, each 10% increase in per capita gross domestic product creates a 7.5% increase in demand for physician services.4 Insurance coverage also influences demand. The uninsured and the underinsured typically delay seeking health care until they are sicker and require more significant health care interventions. To the extent that federal or state policies provide more comprehensive insurance coverage, demand for health care will increase.5,6 The application of technology in health care can have differing effects. For example, the widespread adoption of electronic health records can potentially improve physician productivity; however, new technological breakthroughs in the treatment of disease can accelerate demand.5,6 The organization of health care can also promote or inhibit productivity. Highly integrated health care systems tend to be more efficient and improve productivity, but most US physicians continue to work in solo practice or small groups.41,42 Finally, the increasing use of nonphysician providers (eg, physician assistants and nurse practitioners) can substitute somewhat for physician services.5,6
Although some national foundations have decried the lack of a national effort to coordinate health care workforce planning, our system is highly decentralized and fragmented.43,44 Several national organizations like COGME provide advice to federal lawmakers but have no policy-making mandate. Thus, essentially no formal federal mechanism exists for shaping the health care workforce. However, Congress does influence how many physicians are being trained through control of federal GME funding. In fact, the current cap on federal reimbursement for GME positions has become the single most important reason that physician supply is not growing in the United States.16 Although more medical students are in training in the United States than ever before, the slow growth in GME training opportunities will only result in those US graduates crowding out IMGs from existing training programs, not in the growth in the number of practicing doctors.23,24 Although commentators have advocated for reducing our dependence on IMGs in this country,45-47 doing this without planning for domestically producing an appropriate number of physicians seems problematic.
In the absence of federal mandates, states are left to their own devices to plan workforce. In most states, planning is fragmented among different organizations, and coordinated planning is difficult or nonexistent.44 In contrast, Texas has an organized approach to workforce planning. The Department of State Health Services, Center for Health Statistics oversees the collection of data on the health care workforce through the Health Professions Resource Center. These data are used by the Statewide Health Coordinating Council, created by the legislature in 1998, to produce a "Texas State Health Plan" for the governor and the legislature every 6 years.44,48 The plan is updated before each biennial session of the legislature and provides policy recommendations on workforce-related issues that serve as the basis for legislative action. Furthermore, the Texas Higher Education Coordinating Board, which is responsible for overseeing and coordinating higher education in Texas, also periodically reviews and reports on the status of medical education training.36 Finally, the Texas Medical Association, one of the most organized and effective physician advocacy groups in the nation, has a strong interest in workforce issues and periodically issues policy statements and tracks legislation that impacts the physician workforce in Texas.49,50
The National Physician Workforce Today: A Profile
In 2005, approximately 817,000 physicians, including 714,000 full-time equivalents (FTEs), were engaged in active practice or GME training in the United States. The physician-to-population ratio has been growing over the past 20 years (from 202 per 100,000 to 276 per 100,000) and is projected to reach 283 per 100,000 by 2010.5,6,37 Under current production and practice patterns, the supply of FTE physicians is projected to increase to about 970,000 by 2020, but growth is expected to slow after 2010, as the large number of physicians in the baby boom generation begin to retire.5 The rate of population growth in the United States will begin to exceed growth in physician supply after 2015, so that the per capita number of physicians will increase to 301 per 100,000 by 2015 and then begin to decline thereafter. The various forecasting models project the physician shortage to be anywhere from 60,000 to 200,000 by the year 2020, a gap of 5% to 20% of the workforce.4-6
The composition of the workforce has been slowly changing. Women now constitute nearly 50% of graduates and 49% of applicants at US medical schools but still only 26% of the practicing physicians.5,6 This has important implications for the workforce as women, all other things being equal, do not practice as many hours per week as their male counterparts. Furthermore, current male graduates of medical schools are opting to work fewer hours than previous generations of physicians, exacerbating the trend towards a decline in clinical FTEs per medical school graduate.16,23
The minority population, particularly the Hispanic population, of the United States is increasing more rapidly than the majority Caucasian population. Minority groups account for more than 33% of the nation's population, but Asian (5.7%), African-American (3.3%), Latino (2.8%) and Native American (0.3%) combined account for only 12.1% of the physician workforce.51 A further 23.6% of the workforce is made up of IMGs.51 Although Asians are overrepresented in medical schools versus their percentage in the population (20% of matriculating students, 6% in the US population), other minority groups combined only represent about 14% of matriculating students. Despite significant efforts, applications from non-Asian minorities have only increased from 3,400 to 6,200 in the period from 1977 to 2007; from 1995 to 2007, these graduates increased by only about 500, from 1,844 to 2,400.51 Clearly, much work remains to be done to create a physician workforce that reflects the general population.
In response to the most recent AAMC statement on the physician workforce, calling for a 30% increase in the number of medical school seats, 108 of the existing 130 medical schools in the United States have expanded or plan to expand their class sizes.52 First-year MD enrollment is up 5% from the year 2002 and now consists of 17,300 students nationally.51 Most of this growth has resulted from expansion of existing schools, but the national accrediting body for medical schools, the Liaison Committee on Medical Education (LCME), has accredited five new schools and has received applications for accreditation from 5 more.53The AAMC is projecting that, by 2012, first-year enrollment will be 19,500 (18% above 2002) but still short of the 30% level52 ( Figure 2 ) [ PDF ].
In addition to allopathic medical school expansion, osteopathic medicine is undergoing rapid growth, with first year enrollment expected to double between years 2002 and 2015 to about 6,000 annual graduates.24,52 Finally, significant growth has occurred in foreign medical education programs designed to feed into US GME. Many of these programs are in the Caribbean. The number of IMGs entering GME in the United States has grown 21% over the past decade.54
The combination of increased DO and MD output will result in a total compliment of 25,500 US graduates by 2015, adding 6,000 new graduates per year over current production levels.24 However, adding medical school seats without expanding GME will not increase supply. In the 10 years since the federal GME funding caps have been in place, the number of first-year GME positions has grown by about 1,000 and total positions have grown by 6,000.16 At present, 25,000 first-year positions and 105,000 total GME positions are available annually.13 Thus, GME has continued to expand, even in the face of federal funding constraints, but not fast enough to cope with the ramping up of medical school production. Furthermore, most of the growth in positions has been in subspecialty fellowships, not entry-level slots. Cooper estimates that an additional 10,000 first-year residency slots would be needed to completely address the physician shortage of 200,000 that he predicts for the year 2025.16
A final challenge facing the physician workforce is the declining interest of US medical graduates in primary care. From 1997 to 2004, the proportion of graduates entering primary care residencies declined from 53.4% to 35.1%, while hospital-based specialties increased from 12.4% to 24.2% and surgical specialties increased from 15.9% to 19.1%.55 The percentage of US graduates choosing family medicine declined from 14% in 2000 to 8% in 200556 and, in 2008, only 44.2% of family medicine slots offered were filled by US graduates.57 Three-quarters of graduating internal medicine residents now pursue careers as hospitalists and subspecialists rather than as primary care providers.58
At least one reason commonly advanced for this alarming trend is the growing income gap between primary care and specialty care.59 In 2005, the median income for family physicians was $156,000, while median income was $428,000 for invasive cardiologists, $350,000 for hematologists/oncologists, and $407,000 for diagnostic radiologists.59 With students graduating with median debt of $120,000 at public medical schools and $160,000 at private schools, the prospect of a primary care practice with a large panel of patients and many after-hours responsibilities is not attractive compared with a specialty practice with more regular hours and a higher income.59,60 The AAMC estimates that the shortage of primary care physicians will amount to roughly 45,000 by 2025, about one-third of the total doctor shortfall.6
The shortage of primary care doctors is exacerbated by geographic variations in supply.6 Rural and inner-city urban areas are already experiencing shortages of primary care doctors. Furthermore, IMGs constitute an increasing percentage of the US primary care workforce (18.6% in 1980 versus 28.3% in 2007).45 If the supply of IMGs is constrained for any reason, will US graduates apply to fill the gaps that would result in primary care residency programs? 13 Adjustments to our system for the reimbursement for health care services will be necessary to make primary care an attractive career option. The enhanced payments being discussed for the coordination of care function in the "medical home" model could be a step in the right direction.41 Medical school programs with a specially focused rural curriculum have worked to increase the supply of primary care doctors in underserved areas,61 as have loan forgiveness programs like the National Health Service Corps.5
The Texas Health Care Workforce
Texas is the second most populous state in the nation, with 23 million people. Its population is projected to increase rapidly and will approach 28 million by 2020.62 Texas will also become more diverse, with Hispanics replacing Caucasians as the largest group in the population by 2020.62 The Hispanic population tends to be younger and have less health insurance coverage, and more chronic medical conditions (eg, obesity and diabetes).63,64 Furthermore, Texas has the highest percentage of population without health insurance of any state at 25% (the national average is 15%).65 On many indicators, the Texas health care system is not performing optimally. In a recent Commonwealth Fund scorecard report,66 the state ranked 49th overall and was 51st in access, 46th in quality, 49th in equity, 48th in avoidable hospital use, and 24th in healthy lifestyles.
Part of the poor performance of the health care system is attributable to a shortage and maldistribution of physicians ( Figures 3 , 4 ) [ PDF ]. In 2007, the state had 37,000 direct patient-care physicians. This is an increase of about 8,000 over the 28,800 physicians in practice in Texas in 1998.67 The ratio of practicing physicians-to-population increased from the level of 152 per 100,000 in 2002 to 157 in 2008 but is still well below the national average of 220, and the gap is increasing.68 In physician-to-population ratio, Texas ranks 42st and lowest of the 10 most populous states.69 In 2007, Texas had 171 per 100,000 direct patient care physicians in metropolitan areas, 145 in border metro areas, 89 in nonmetro, nonborder areas, and 71 in nonmetro, border areas.67 Seventy-five per cent of the direct patient care physicians were male (median age, 51 years) and 25% female (median age, 44 years). Forty-five per cent of the Texas physician population were older than 50 years. Sixty-six per cent were Caucasian; 4.6%, African-American; 11.5%, Hispanic; and 17.9% listed other as their race.67
In 2007, Texas had 16,120 primary care doctors in practice, up from 12,800 in 1998 ( Figures 5 , 6 ) [ PDF ].67Texas ranks 47th in the supply of primary care physicians with a ratio of 68 per 100,000, versus the US average of 88 per 100,000.69 In 2005 one hundred sixteen of the state's 254 counties were federally designated as health professions shortage areas (meeting the qualification of having less than 1 primary care physician per 3,500 residents), and an additional 60 counties were partially designated.67 In 2005, primary care supply ratios in Texas were 53 per 100,000 in rural areas versus 71 per 100,000 in urban areas. The border region is particularly underserved, with supply ratios of 62.5 generally and 45 in rural border counties.67 Sixty-six percent of the primary care workforce was male (median age, 48 years) and 34% female (median age, 42 years). Caucasians made up 59%, African-Americans 6%, Hispanics 14%, and other races 20% of the primary care workforce. In Texas, doctor-to-population ratios for all primary care disciplines have been static or declining.67 Data for 2007 reveal that 36.7% of primary care doctors are in solo practice, 47% are in groups, and 12% are employed by hospitals.68
Several specialty areas besides primary care have been noted to be in particularly short supply in Texas. Fifteen hundred psychiatrists and child psychiatrists were practicing in 2007, and the psychiatrist-to-population ratio has been declining steadily since the early 1990s.67 Geriatricians are also in critically short supply, an especially serious concern with the aging of our population.70
A 2009 consensus statement issued by TMA and the state's training institutions, in advance of the 2009 legislative session, found that the state had shortages in 37 of 40 major medical specialties, compared with national averages, and concluded that the state needs 27% more physicians to reach the national average for physicians per 100,000 population.50
Thus, the overall picture for the Texas workforce shows an existing shortage of physicians, both in primary care and in some specialty fields. The shortage is most marked in border and rural areas; however, even in the best supplied areas, which tend to be the major metropolitan centers, the physician-to-population ratio lags behind national averages, and the gap is growing. Also of concern is the high median age of the existing physician workforce and the fact that the workforce does not reflect the state's general population, especially with respect to the representation of women and minorities. The shortage of primary care physicians is particularly problematic: a recent statewide workforce symposium stated, "Numerous studies suggest that patients with a primary care physician benefit with improved outcomes and decreased cost to the health care system as a whole."71
Texas now has 9 medical schools with the addition of the Texas Tech University Paul L. Foster School of Medicine in El Paso in 2009. Most of these schools have implemented planned class size expansions. The schools and their current class sizes consist of the seven public allopathic schools: UT Southwestern in Dallas, 218, no change; UT Houston, up from 205 to 230; UTMB Galveston, up from 201 to 230; UT San Antonio, 219, no change; Texas Tech at Lubbock, up from 135 to 143; Texas Tech at El Paso, initial class size 40; and Texas A&M, up from 75 to 107; one public osteopathic school (University of North Texas, Fort Worth, up from 125 to 165); and one private allopathic school (Baylor, Houston, no change 170).36 In total, first-year class sizes increased to 1,480 in 2007-2008, up about 150 positions since 2005.36 Since 2002, interest among Texas college graduates in a career in medicine has remained high, and total applications to public medical schools are up 40% to 4,128.36
Texas ranks 25th in medical students enrolled per 100,000 population, 7th among the 10 most populous states.69 In 2007-2008, a total of 5,861 medical students from Texas were enrolled in medical schools across the United States, 85% of them in Texas. Texas had the third largest number of entering first-year students among the 10 most populous states in 2007-2008.69 Compared with 1998-1999, when Texas had 1,255 in-state medical school graduates, Texas medical schools graduated 1,314 students in 2006-2007; for the first time, females outnumbered males among graduates (662 to 652).38 White and Asian graduates were overrepresented compared with their population in the state (white, 49% of the population, 58% of the graduates; Asians, 3.8% of population, 26% of graduates), and Hispanics and African-Americans were underrepresented (African-Americans, 11.4% of population, 5.3% of graduates; Hispanics, 36% of population, 11.6% of graduates). Since 1998, little change has occurred in the percentages of graduates from underrepresented groups.36
Regional campuses are another strategy being pursued both nationally and in Texas to accommodate a larger number of medical students and to train them in areas of great physician need. Texas Tech has clinical campuses in Amarillo and Midland-Odessa. Texas A&M has announced plans to expand to two full 4-year campuses with 100 students each in Bryan-College Station and Temple, as well as to establish a regional clinical campus in Round Rock. UT San Antonio is developing a Regional Academic Health Center in the Rio Grande Valley, and UTMB currently has a clinical campus in Austin.38
Medical student education is funded primarily by state formula funding which is allocated on a per student basis. For the 2009-10 biennium, the state's medical schools will receive over $700 million in state medical student funding, allocated at a rate of $52,900 per student.49 In addition, Texas A&M received $37 million to expand its program to two full four-year campuses in Bryan-College Station and Temple, and Texas Tech received $67 million to finance the start-up of the Paul L. Foster School of Medicine in El Paso.49
In 2006, Texas had 6,741 residents and fellows in training; 72% were US allopathic medical graduates; 7%, US osteopathic graduates; and 21%, IMGs. The state ranked 22nd in residents and fellows in training per 100,000 population at 28.7 (national mean, 35.6) and 7th among the 10 most populous states.69 The number of residency slots in the state grew by 10% from 1997 to 2006.
Texas had 1,481 filled first-year GME training slots in 2007, a number equal to the number of seniors graduating from Texas medical schools.36 The shortage of GME training slots in the state represents a major policy issue. A TMA survey found that of Texas medical school graduates leaving the state for residency training, 38% would have stayed had a Texas slot been available for them.72 The loss of these physicians to other states for residency means that many will not return to practice in Texas.
Growth of residency program slots in Texas has been slow for a number of reasons, most of them financial. The cap on federal Medicare reimbursement for new positions has played an important role in holding down the number of new training slots, but in the 2004-2005 biennium, the state also significantly reduced its participation in GME financing. Before that legislative session, Texas, like most other states, "paid" for GME through enhanced Medicaid DRG reimbursements made to teaching hospitals. As the Medicaid program is a federal-state matching program, the state's contributions were matched by federal dollars when this approach was used. Funding for GME in the 2002-2003 biennium via this mechanism amounted to $166 million.73 This practice was discontinued in the 2004-2005 biennium as a cost-containment measure and has not been restored (state owned hospitals have recently been able to use some of their state appropriations to draw down federal Medicaid matching funds. In FY 2009 these monies totaled $20 million.73 ) Medicaid GME was replaced by a capitation payment method that was implemented in the 2006-2007 session.
In the recently concluded 2009 legislative session, total GME funding increased around 18%, including increased capitation payments totaling $80 million for the biennium ($6,600 per resident per year) and Texas Higher Education Coordinating Board (THECB) primary care payments of $26.8 million.49
Texas medical schools and residency programs have done a good job training physicians for the state. Of the physicians in practice, 42% attended a Texas medical school (national mean, 30%) and 50% did their residencies in Texas (national mean, 34%).69 Texas has also retained as active practicing physicians a high percentage of the medical students trained in the state, ranking 2nd nationally at 59% (national mean, 40%). 69 The state also does well in retaining residents and fellows trained in Texas, ranking 7th at 56% versus a national average of 47%, and the retention rate is even better for those who do both medical school and residency in Texas (80% versus a national average of 66%).69
TexasW orkforce: The Future
By 2020, the Texas physician workforce is projected to number 46,800, including 26,600 specialists and 20,200 primary care doctors. The rate of growth in primary care supply will be slower than that of specialty supply.36 Between 2005 and 2015, the state's population is projected to increase 16% to around 26 million.62 During the same period, the number of medical school graduates is expected to climb about 30% to 1,800, and the number of practicing doctors will increase by 20% to 43,00036 ( Figure 7 ) [ PDF ]. Continued rapid population growth combined with increasing diversity and an increase of 30% in the number of Texans older than 65 years mean that Texas, even with relatively significant growth in medical school capacity, will remain a net importer of physicians.36
Discussion and Conclusions
A recent THECB report36 recommended that the state expand and fully fund existing medical schools in the state to increase enrollment by 30% by 2015. The report also recommended further development of regional campuses as an important part of the growth strategy. THECB called for expanding the state's GME training programs to accommodate the increasing number of Texas medical school graduates, suggesting that first-year residency slots be increased to a level 10% greater than the number of medical school graduates and that each position be funded at a level of $7,500. It also advocated for the continuation and expansion of programs designed to attract more minority students to careers in medicine and the expansion of loan forgiveness programs designed to encourage service in underserved areas of the state. Finally, it recommended marketing efforts to attract physicians trained in other states to Texas.
On the basis of the best available evidence, the United States is already experiencing a shortage of physicians, at least in some regions, and almost certainly will face a shortage in the future. The shortage will be worse in some parts of the country, especially rapidly growing states in the west and south, rural areas, and inner cities. All specialties will probably be in short supply, but primary care will be impacted most and, as primary care doctors are the backbone of the health care system, this has troubling implications. The shortage will manifest itself in many ways: longer waiting times for appointments, shorter visits with physicians, increasing use of physician extenders, longer travel distances to get needed care, and higher prices. In some cases and in some areas, no physicians will be available to provide care to populations of patients. In a country already struggling to provide basic care to many of its citizens, a physician shortage will only complicate matters further.
The dramatic expansion of medical student education in the United States is a noteworthy trend. The significant class size expansions occurring at many medical schools, the growth of regional clinical campuses, and the founding of entirely new medical schools (both allopathic and osteopathic) have made medical education a growth industry. Through these efforts, somewhere between 8,000 and 10,000 additional medical school graduates will be produced annually by 2015. Whether enough qualified applicants exist to fill these slots is an open question,74 and the struggles to develop medical school populations that mirror the diversity of the general population will continue.
The critical linchpin of the physician workforce remains GME. Without increasing the number of GME training slots in the United States, the rapid expansion of medical schools will not be translated into a larger physician workforce. The critical issue here is funding. Given the challenging financial situation facing the nation and the federal budget, the possibility that the cap on Medicare funding of GME positions will be lifted anytime soon seems remote. That being said, lifting that cap would be the single most effective way to increase physician supply in this country. Absent that, we are left with relying on the states, teaching hospitals, and medical schools to fund GME expansion. Given the financial challenges these entities face, they are unlikely to underwrite large numbers of new positions, but some incremental expansion is likely. Whether that expansion will be enough to exert a meaningful impact on physician supply is unknown.
Texas faces many of the same workforce challenges being experienced nationally; however, these challenges may be greater for Texas because the state has historically had physician-to-population ratios well below national averages and is growing rapidly. If current trends continue, Texas is likely to continue to experience a shortage and maldistribution of physicians into the indefinite future. At this time, Texas is not training enough physicians in the state to meet its immediate or its long-term needs. Thus, in the face of a growing national shortage of physicians, the state must rely on importing a large number of physicians trained elsewhere to meet its needs.
Shortages of primary care physicians will continue to worsen in Texas, especially in the rural and border areas. The lack of adequate access to primary care, combined with the large population of uninsured and underinsured patients, will continue to challenge the health care infrastructure, resulting in greater burdens of preventable illness at high cost to the state's economy. In addition to primary care shortages, the mental health system will be impacted by a relative decline in the number of practicing psychiatrists, and the aging population will not have access to the necessary number of geriatric specialists. Finally, shortages are likely in many surgical specialties, and those specialties that are available will cluster in urban areas, creating gaps in other parts of the state.
Texas medical schools have responded to the call to produce more doctors by increasing class sizes, and this is certainly important in addressing the "doctor gap." At this point, the number of first-year slots is the same as the number of graduating senior medical students. The lack of GME training slots available forces some graduates of Texas medical schools, trained here at taxpayer expense, to leave the state for residency training. Some of these graduates never return. Ironically, although forced to import physicians to meet its needs, Texas is still exporting physicians schooled here to other states.
The single most important step Texas could take to address its physician shortfall is a major investment in expanding GME training. The expansion of formula funding in the 2009 legislature was a positive development, but funding at the level of $6,600 per position per year is insufficient to induce teaching hospitals and medical schools to create new training positions. Texas faces many financial challenges, and many priorities are worthy of the limited state dollars available. The long training process to produce physicians means that an investment now will take from 7 to 10 years to come to fruition; given the more limited time horizon of other equally pressing issues, to put off investing in GME would be tempting. However, an inadequate physician workforce now and in the future challenges the vibrancy of the state's economy and its capacity to grow. Thus, painful as it may be, the time to act is now.
- Summary of Third Report: Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century . Washington, DC: US Dept of Health and Human Services, Health Resources and Services Administration, Council on Graduate Medical Education; 1992.
- Cooper RA. Perspectives on the physician workforce to the year 2020. JAMA. 1995;274:1534-1543.
- Weiner JP. Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA. 1994;272(3):222-230.
- Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21(1):140-154.
- Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020 . Washington, DC: US Dept of Health and Human Services, Health Resources and Services Administration, Council on Graduate Medical Education; 2005.
- Dill MJ, Salsberg ES. The Complexities of Physician Supply and Demand: Projections through 2025 . Washington, DC: Association of American Medical Colleges, Center for Workforce Studies; 2008. http://www.tht.org/education/resources/AAMC.pdf .
- Guckian JC, Zetzman MR, Mullins, CB. Physician workforce in Texas: planning for the future. Tex Med . 1995;91(11):50-57.
- Kennedy VC, Spears WD. Supply and distribution of primary care physicians and medical school enrollments in Texas. Tex Med. 1994;90(9):60-70.
- Ludmerer KM. Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care . New York, NY: Oxford University Press; 1999.
- Ginzberg E. Physician supply in the year 2000. Health Aff (Millwood) . 1989;8(2):84-90.
- Bane F. Physicians for a Growing America: Report of the Surgeon General's Consultant Group on Medical Education . Washington, DC: US Public Health Service, Dept of Health, Education, and Welfare; 1959. Publication no. 709.
- Star P. The Social Transformation of American Medicine . New York, NY: Basic Books; 1982.
- Iglehart JK. Medicare, graduate medical education, and new policy directions . N Engl J Med. 2008;359(6):643-650.
- S Rep. No. 404, 89th Cong., 1st Sess. (1965).
- HR Rep. No. 213, 89th Cong., 1st Sess. (1965).
- Cooper RA. It's time to address the problem of physician shortages: graduate medical education is the key. Ann Surg . 2007;246(4):527-534.
- Graduate Medical Education National Advisory Committee. Summary report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services . Vol 1. Washington, DC: Government Printing Office; April 1981. DHHS publication no. (HRA) 81-651.
- Blumenthal D. New steam from an old cauldron: the physician-supply debate. N Engl J Med. 2004;350(17):1780-1787.
- Summary of the Fourth Report: Recommendation to Improve Access to Health Care Through Physician Workforce Reform . Washington, DC: Council on Graduate Medical Education; 1994.
- Summary of the Eighth Report: Patient Care Physician Supply and Requirements: Testing COGME's Recommendations . Washington, DC: Council on Graduate Medical Education; 1996.
- Cohen JJ, Todd JS. Association of American Medical Colleges and American Medical Association joint statement of physician workforce planning and graduate medical education reform policies. JAMA . 1994;272(9):712.
- Dunn MR, Miller RS, Richter TH. Graduate medical education, 1997-1998. JAMA . 1998;280(9);809-812.
- Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med. 2006;81(9):782-787.
- Iglehart JK. Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med . 2008;358(16):1741-1749.
- Recent studies and reports on physician shortages in the US . Washington, DC: Association of American Medical Colleges, Center for Workforce Studies; 2007.
- Johnson WG, Rimsza ME, Garcy T, Grossman M. The Arizona Physician Workforce Study, part I: The Numbers of Practicing Physicians 1992-2004 . Phoenix, AZ: Arizona State University and the University of Arizona Health Sciences Center; 2005.
- Salsberg E, Center for Health Workforce Studies. California Physician Workforce Supply and Demand Through 2015 . Albany, NY: State University of New York at Albany; 2004.
- Schubert A, Eckhout G Jr, Tremper K. An updated view of the national anesthesia personnel shortfall. Anesth Analg . 2003;96(1):207-214.
- Fye WB. Cardiology's workforce shortage: implications for patient care and research. Circulation . 2004;109(7):813-816.
- Deal CL, Hooker R, Harrington T, et al. The United States rheumatology workforce: supply and demand, 2005-2025. Arthr Rheum . 2007;56(3):722-729.
- Utah 's Physician Workforce: A Study of the Supply and Distribution of Physicians in Utah . Salt Lake City, UT: Utah Medical Education Council; 2006.
- Barer M. New opportunities for old mistakes. Health Aff (Millwood). 2002;21(1):169-171.
- Weiner JP. A shortage of physicians or a surplus of assumptions? Health Aff (Millwood) . 2002;21(1):160-162.
- Goodman DC, Fisher ES. Physician workforce crisis? Wrong diagnosis, wrong prescription. N Engl J Med . 2008;358(16):1658-1661.
- AAMC statement on the physician workforce. Washington, DC: Association of American Medical Colleges; 2006. http://www.aamc.org/workforce/workforceposition.pdf .
- Projecting the Need for Medical Education in Texas: A Report to the Texas Legislature . Austin, TX: Texas Higher Education Coordinating Board; 2008.
- Physician supply and demand: projections to 2020. Washington, DC: US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions; 2006. http://www.bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/default.htm .
- Evaluation of specialty physician workforce methodologies. Resource paper. Washington, DC: Council on Graduate Medical Education; 2000.
- Goodman DC, Fisher ES, Bubolz TA, Mohr JE, Poage JF, Wennberg JE. Benchmarking the US physician workforce: an alternative to needs-based or demand-based planning. JAMA . 1996;276(22):1811-1817.
- Cooper RA, Getzen TE, Laud P. Economic expansion is a major determinant of physician supply and utilization. Health Serv Res . 2003;38(2):675-696.
- Bodenheimer T. Coordinating care - a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064-1071.
- Mehrotra A, Epstein AM, Rosenthal MB. Do integrated medical groups provide higher-quality medical care than individual practice associations? Ann Intern Med . 2006;145(11):826-833.
- Out of Order, Out of Time: The State of the Nation's Health Workforce . Washington, DC: Association of Academic Health Centers; 2008.
- Moskowitz MC. StateActions and the Health Workforce Crisis . Washington, DC: Association of Academic Health Centers; 2007. http://www.aahcdc.org/policy/reddot/AAHC_Workforce_State_Actions.pdf .
- Starfield B, Fryer GE Jr. The primary care workforce: ethical and policy implications. Ann Fam Med. 2007;5(6):486-491
- Ahmad OB. Managing medical migration from poor countries. BMJ . 2005;331:43-45.
- Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005:353:1810-1818.
- 2007-2008 Texas state health plan update. Austin, TX: Texas State Health Coordinating Council, Center for Health Statistics, Department of State Health Services; 2006.
- Political Prognosis: TMA Scores Wins in Legislative Session. http://www.texmed.org/Template.aspx?id=7751 . Accessed October 20, 2009.
- 2009 Medical Education and Physician Workforce. Consensus Statement. Austin, TX.: Texas Medical Association, 2009.
- Diversity in the Physician Workforce: Facts and Figures 2006 . Washington, DC: Association of American Medical Colleges; 2006.
- MedicalSchool Enrollment Plans: Analysis of the 2007 AAMC Survey. Washington, D.C: Association of American Medical Colleges, Center for Workforce Studies, 2008.
- Institutions with developing medical education programs that have applied for preliminary accreditation by the LCME (updated 10-9-08). http://www.lcme.org/newschoolprocess.htm . Accessed October 20, 2009.
- Salesberg E. Increasing medical school enrollment: rationale and implications for medical schools and GME. Paper presented at: American medical Association Section on medical Schools; November 11, 2006; Las Vegas, NV.
- Jeffe DB, Andriole DA, Hageman HL, Whelan AJ. The changing paradigm of contemporary US allopathic medical school graduates' career paths: analysis of the 1997-2004 national AAMC graduation questionnaire database. Acad Med. 2007;82(9):888-894.
- Pugno PA, Schmittling GT, Fetter GT Jr, Kahn NB Jr. Results of the 2005 national resident matching program: family medicine. Fam Med . 2005;37(8):555-564.
- 2008 NRMP results, family medicine. http://www.aafp.org/online/en/home/residents/match/table1.html . Accessed November 24, 2008.
- West CP, Popkave C, Schutlz HJ, Weinberger SE, Kolars JC. Changes in career decisions of internal medicine residents during training. Ann Intern Med. 2006;145(10):774-779.
- Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146(4):301-306.
- Rosenblatt RA, Andrilla CH. The impact of US medical students' debt on their choice of primary care careers: an analysis of data from the 2002 medical school graduation questionnaire. Acad Med. 2005;80(9):815-819.
- Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. Acad Med. 2008;83(3):235-243.
- Projections of the population of Texas and counties in Texas by age, sex and race/ethnicity for 2000-2040. Texas State Data Center and Office of the State Demographer Web site. . Accessed November 11, 2008.
- Hargraves JL, Hadley J. The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access of care. Health Serv Res. 2003;38(3):809-829.
- The Changing Healthcare Workforce in Texas: Resources Versus Needs . Austin, TX: Texas Institute for Health Policy Research; 2004.
- Code red: the critical condition of health in Texas. http://www.coderedtexas.org/ . Accessed November 24, 2008.
- Cantor JC, Schoen C, Belloff D, et al. Aiming Higher: Results From a State Scorecard on Health System Performance . New York, NY: Commission on a High Performance Health System, The Commonwealth Fund; 2007.
- Supply Trends Among Licensed Health Professions: Texas, 1980-2007 . Austin, TX: Health Professions Resource Center, Center for Health Statistics, Texas Department of State Health Services; 2007.
- Promoting Excellence Through Healthcare Workforce Planning in Texas . Austin, TX: Health Professions Resource Center, Center for Health Statistics, Texas Department of State Health Services and Statewide Health Coordinating Council; 2007.
- 2007 State Physician Workforce Data Book . Washington, DC: Center for Workforce Studies, Association of American Medical Colleges; 2007.
- Highlights: The Supply of Primary Care Physicians in Texas - 2005 . Austin, TX: Center for Health Statistics, Health Professions Resource Center, Texas Department of State Health Services and Statewide Health Coordinating Council; 2006.
- The state of primary care delivery in the United States. Austin, TX: Policy Brief, Statewide Health Workforce Symposium, Statewide Health Coordinating Council; 2004.
- Texas Medical Association. Why Texas needs more physicians. http://www.texmed.org/Template.aspx?id=5427 . Accessed January 3, 2007.
- Personal communication: Patrick Francis, Assistant Vice Chancellor for Health Affairs, University of Texas System, Austin, TX., October 20, 2009.
- Garrison G, Matthew D, Jones RF. Future medical school applicants, part I: overall trends. Analysis in Brief. May 2007;7(3). Washington, DC: Association of American Medical Colleges.
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