GME a Top Priority for 2015 Legislature

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Education Feature — May 2015

Tex Med. 2015;111(5):45-50.

By Amy Lynn Sorrel
Associate Editor

When national resident Match Day rolled around in March, fourth-year osteopathic medical student Blair Cushing had a singular goal as she headed into her postgraduate training: "I want to focus on rural practice and do the full spectrum of family medicine — seeing patients in the hospital, delivering babies. So it takes a specific program to come out fully prepared for that." 

The Texas College of Osteopathic Medicine student preferred to stay in Texas, but applied to dozens of graduate medical education (GME) programs across the country to increase her chances in the highly competitive match process. She did not get her wish and is headed to California to complete her residency training.

That's despite the fact that in Texas, the odds for Ms. Cushing's class went up this year, thanks to an additional $14.5 million the 2013 Texas Legislature put toward additional residency slots through a slate of new GME expansion grant programs. Just in time for the 2015 match, those grants helped open up more than 70 first-year slots that were either new or previously unfilled because teaching hospitals could not afford the cost.

The 2013 boost was a good start, but there's plenty of room to grow, Ms. Cushing says. 

Many of the Texas residency programs she visited are at capacity in terms of positions they can afford to fund and in terms of applications they receive. She interviewed in El Paso in early November — before applications had closed — and the family medicine residency program there already had received 2,000 applications for eight positions. Only 64 would get interviews. 

"Working with students from other states, I'm always happy to report back that Texas took the bull by the horns, and when we said we needed more spots, they [lawmakers] did the right thing and put up more money," said Ms. Cushing, a former student representative to the Texas Medical Association's Board of Trustees and member of the American Medical Association's Medical Student Section. 

"There's huge interest, and graduates want to come. But we still just don't have enough spots for them," she warns. Not only do those slots secure a pathway for doctors-in-training to enter the workforce, "when programs know they have additional money behind them, they can be more innovative," she said, and provide the kind of broad training she seeks and Texas — with its ever-growing population — needs. 

Top Priority

GME expansion is the top priority for medicine this legislative session, and thanks to years of advocacy coming to fruition, the issue is top of mind for lawmakers, too. 

As this story went to press, more GME money made its way into budget proposals, and a handful of bills build on the momentum started last session to grow the physician workforce in Texas with the creation of additional GME grant and physician education loan repayment programs.

Educators across the state welcome the attention. As new grants are added, however, they also want to ensure long-term funding that matches institutions' intensive commitment to host or expand training opportunities without creating mechanisms that unnecessarily complicate the GME funding process. They also want GME money to match the state's workforce needs across specialties. 

With a characteristically tight state budget taken up by public education, Medicaid, and prisons, "it feels like GME is always at the end of the line. This is the first year it feels like GME is at the front of the line," said TMA Council on Medical Education Chair Rodney Young, MD. "We spent years reinforcing our message, and it may have been heard, but this year [the legislature] has the resources to act on it."

Especially with federal funding frozen for hospitals that already have GME, TMA leaders and Texas educators urge the state to double down on its commitment.

The legislature's two-year funding cycle, for example, falls short of the three or more years it takes to fully prepare a resident for independent practice, Dr. Young notes. The 2013 grants funded only the early training years. Money earmarked for additional residency years was placed on hold until this session.

The expansion grants were "definitely successful, but they were probably more complicated than they needed to be," he adds. The Texas Higher Education Coordinating Board (THECB) spent months writing rules and pushing deadlines to implement a matrix of grants, while GME programs spent their own time and resources deciphering which awards they qualified for and submitting applications. 

TMA advocates for a simplified process free of hurdles that could restrict eligibility or deter participation because without help to sustain GME programs' long-term commitment, "graduates are going to go elsewhere and take the state's $170,000 investment with them," Dr. Young warns.

Lawmakers got the message.

Recommendations by the Legislative Budget Board (LBB) to the 2015 legislature acknowledge the need to better "align new GME funding with the health care needs of the state," and House and Senate budget drafts add roughly $30 to $60 million, respectively, over the 2016-17 biennium to fund residency slot expansions. It is up to a legislative conference committee to work out the differences. 

The major vehicle to put that money into action and reach TMA and THECB's goal of 1.1 entry-level GME slots per medical school graduate is Senate Bill 18 by Senate Finance Committee Chair Sen. Jane Nelson (R-Flower Mound), and Sens. Juan "Chuy" Hinojosa (D-McAllen) and Kel Seliger (R-Amarillo). The legislation proposes another set of GME expansion programs at THECB that target critical shortage specialties and underserved areas in the state. 

The boost builds on medicine's successes in the 2013 session when, after slashing GME funding during a 2011 budget crisis, the legislature approved a $30 million or 45-percent increase in state GME funding. 

About half of the money was dedicated to a new GME expansion strategy that included:   

  • Planning grants to help nonteaching hospitals explore the feasibility of starting a residency program for the first time; 
  • Funding for existing but unfilled first- and second-year slots; and 
  • Money to expand existing or build new GME programs.  

This year's budget proposals also consider an increase in formula funding — per-resident amounts — to health-related institutions. Among other workforce-related bills, Senate Bill 239 by Sen. Charles Schwertner, MD (R-Georgetown), would offer student loan repayment assistance for psychiatrists, psychologists, advanced practice nurses, and other health care workers providing mental health care in underserved areas. 

Senator Nelson says there is "strong support" to address GME this session, describing the prospects for increased funding as "very likely." 

"A robust health care workforce is essential to ensuring that our citizens have access to care," she said. "Last session, the legislature made progress on graduate medical education, specifically toward our goal of keeping medical school graduates in Texas. Those investments have started us down the right path. This session, we have a healthy budget outlook, and there have been several new ideas discussed to grow our residency spots and encourage residents to practice in areas where they are most needed."

Barely Breaking Even

Action is more critical than ever, according to the Association of American Medical Colleges' (AAMC's) March prediction of a national shortage of nearly 46,000 to 90,000 physicians by 2025. That includes shortages in both primary care and specialty care "with specialty shortages particularly acute," an AAMC statement reads

Texas' exponential population growth has exacerbated the state's need, Dr. Young says. The state's medical schools also exceeded the goal AAMC set more than a decade ago to increase enrollments by 30 percent. Meanwhile, three new schools come online in the next two years — with an estimated 250 graduates by 2020. At least two more medical schools are under consideration. 

Texas GME is barely keeping up. In 2014, Texas had 1,641 first-year spots for 1,611 MD/DO graduates. (See "A Long Road Ahead.") 

"We are at a break-even point now. And without the funding the last time around, I'm not sure we would be at that point at all," said THECB Deputy Assistant Commissioner for Academic Quality and Workforce Stacey Silverman, PhD. "This was an excellent first step to try and create additional positions in the state. But there's a long way to go."

Agreeing that some of the grants were too prescriptive and complex for programs to navigate, she said, "The legislature is looking at ways to streamline the process and encourage more participation and greater eligibility, which will help benefit everybody: the medical schools, the hospitals, and their communities." 

So far, THECB awarded most of the GME expansion grant money to fund 78 first-year residency positions in 2015. Twenty-five entry-level positions created in 2014 will get funding as second-year slots in 2015. In addition, 10 one-time grants seeded hospitals that never had a residency program with $150,000 to explore offering GME, which will lead to the creation of five new residency programs. 

Still, "the commitment has to be there to maintain them for the duration of that training," Dr. Silverman said. 

THECB asked the legislature for another $40 million on top of the 2013 funding to continue last session's GME expansion efforts, plus an additional $16 million for the family practice residency program, financial support to incentivize residents to choose family medicine as their specialty, and practice in rural and underserved areas. Also key to program sustainability is per-resident, or formula, funding, she says, which THECB asked the legislature to increase by about 39 percent. 

TMA supported THECB's budget requests and also asked lawmakers to restore and increase funding for the primary care preceptorship programs — state stipends to encourage medical students to choose primary care — to catch up with the state's primary care needs. 

Senator Nelson says her bill includes a "three-pronged approach" that prioritizes primary care, specialties experiencing shortages, and geographic areas experiencing shortages. A new Critical Shortage Physician Program she described would allow a panel of experts to recommend which areas are most in need of new physicians, with regards to specialties and geography, and "based on those reports, incentives would be provided to teaching hospitals to create and maintain residency programs for those critical shortages."

She says that consistency would come from "a long-term funding source" created under SB 18 with a $300 million endowment derived from the dissolution of the Texas Medical Liability Insurance Underwriting Association (JUA). The insurer-of-last resort provides medical liability insurance to physicians unable to obtain it elsewhere in the private market. 

TMA supports the creation of a physician-led advisory committee at THECB to help oversee the GME grant process and identify critical shortage areas. Even the LBB's recommendations acknowledge that "no national, or state government, or independent workforce entity exists to guide policymakers and stakeholders about the appropriate physician mix needed to meet the population's current and future health care needs." 

But TMA officials raised grave concerns that the dissolution of the Texas JUA would draw lawsuits if any money left is redirected away from JUA policyholders or unfunded liabilities. Elsewhere, legal action successfully halted state raids on similar medical liability funds to plug budget holes.

Long-Term Commitment 

The University of Texas Southwestern Medical Center in Dallas qualified for only two of the five new THECB grant programs. But that helped put two psychiatrists-in-training in previously accredited but unfilled positions the hospital could not afford to fill.

"Texas needs primary care, but we also need specialty care, and that's just a function of a growing state requiring all dimensions of medical care," Associate Dean of GME Bradley Marple, MD, said. He also chairs UT Southwestern's otolaryngology department. "We know we are about 50 percent below the number of psychiatrists we need in the state, so this was a great win-win opportunity." 

The medical center also took advantage of a grant to add a new GME program, in this case, one designed and accredited to train primary care residents with an expertise in pediatrics and internal medicine. "There again, we are addressing shortfalls in the state and training in a niche we felt we needed," Dr. Marple said.

He praised the legislature for "stepping up and taking responsibility for training residents. But the bigger threat is to the long-term sustainability of these programs." 

Unless lawmakers renew their commitment, the two-year funding UT Southwestern receives for the psychiatry slots and the one-year funding for the new primary care program will run out long before the three to seven years it takes to fully prepare residents for the workforce.

"We have a contractual and moral obligation to train these residents. We are committed to that, and we would have to tighten our belts somewhere else. But if programs don't have the ability financially to make that work beyond that point, it could compromise the whole program," Dr. Marple said. "It's very encouraging to see the legislature during this cycle take the same charge and move forward in creating funding sources that will be sustainable. And it's nice to see that we are all embracing and responding to this challenge."

In Sulphur Springs, Hopkins County Memorial Hospital took the plunge to launch a family medicine residency program in partnership with UT Health Northeast in Tyler. With the help of a planning grant, the hospital figured it could host four residents. 

"We are extremely excited because our philosophy has been: We have to grow our own. We know we can use four new doctors a year in our community, and all the research supports the fact that residents don't travel too far from their training to set up practice, so we won't have to travel the country" to recruit, the hospital's Chief Executive Officer Michael McAndrew said.

But he knows the real work lies ahead to support that physician supply. That's also contingent on the legislature following through on its 2013 promise to fund positions created out of the planning grants at $35,000 per resident per year, above the Medicare funding hospitals that never before hosted GME are eligible to receive.

"The latest headline I saw, again, predicts a huge shortage of family practice physicians, and we are trying to do our part. But when you are a small, rural hospital in Texas, you are already losing money, and we project to lose money on this," Mr. McAndrew said. "The inherent benefit in doing this has incalculable value. But there are only going to be so many small hospitals doing these programs, and we can use all the help we can get." 

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

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May 13, 2016

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