Making More Doctors

Legislature to Examine Physician Workforce

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Legislative Affairs Feature – January 2012

Tex Med. 2012;108(1):31-35. 

By Ken Ortolon
Senior Editor

Texas needs more doctors. The state's average of 162 physicians per 100,000 residents lags far behind the national average of 250 per 100,000. And shortages in the primary care fields are particularly acute. The federal government considers some 114 Texas counties full primary care health professional shortage areas (HPSAs) and has designated another 47 counties partial HPSAs. Twenty-five counties have no physicians at all.

But the legislature is about to focus some major attention on the state of Texas' primary care workforce. Texas House Speaker Joe Strauss (R-San Antonio) directed the House Committee on Public Health to review the adequacy of the state's primary care workforce and recommend ways to increase patient access to primary care. It's among the issues legislators will examine during the interim period between the 2011 and 2013 legislative sessions.

Texas Medical Association officials applaud the decision of Speaker Strauss and House Public Health Chair Lois Kolkhorst (R-Brenham) to address primary care access problems.

"Most of us would agree that our primary care physician workforce is way below the national average," said Fort Worth pediatrician Gary Floyd, MD, chair of TMA's Council on Legislation. "And there is going to be increased demand for services because of an aging population and a growing population," he said.

But Dr. Floyd says one aspect of the interim charge regarding "expanded roles for physician extenders" could set the stage for another fight over independent practice for nurse practitioners and other physician extenders.

"If by 'expanded roles' they mean independent practice, I don't think that's the right direction," Dr. Floyd said.

Examining the Charge

Speaker Strauss directed the public health committee to examine the adequacy of the primary care workforce in Texas and assess the impact of an aging population, the passage of the Affordable Care Act, and state and federal funding reductions to graduate medical education and physician loan repayment programs. His charge also directs the committee to study the potential impact of medical school innovations, new practice models, alternative reimbursement strategies, and greater utilization of telemedicine.

The panel is to make recommendations by next January to increase patient access to primary care and address geographic disparities.

State Rep. John Zerwas, MD (R-Richmond), is a member of the public health committee. He says it is an important charge, "especially in light of health care reform and what we're going to see as an increasing burden on the whole infrastructure for delivering health care."

Representative Kolkhorst says it is "clear that the current levels of the primary care workforce in Texas and across the nation are indeed below demand, especially now as the state as a payer of health care is moving toward value-based purchasing. We have a number of physicians who are at or nearing retirement and a growing addition of patients through the Affordable Care Act, if it meets constitutional muster. We as a state must take some bold actions to meet the basic health care needs of our citizens."

Dr. Floyd says the committee needs to keep two priorities in mind during its interim study.

"First, it is imperative to maintain our tort reforms so we can attract as many physicians – both specialty and primary care – as possible from other states to our state," he said.

The overall physician workforce in Texas has grown from 157 to 162 per 100,000 since the legislature passed the reforms in 2003, and the Texas Medical Board has licensed record numbers of new physicians over that time.

Second, Dr. Floyd says, Texas must train more physicians and place more emphasis on expanding the number of residency slots and less emphasis on increasing medical school enrollment.

"We don't have enough places for our current graduates to train," Dr. Floyd said. "We invest more than $200,000 per student, and if one of them walks out of our state and goes to another state for residency training, the chances of that doctor settling in that other state are high. That's very frustrating."

Representative Kolkhorst agrees, calling the recent expansion of medical school slots in the state without a corresponding increase in graduate medical education (GME) positions "a bad business model at best."

"We should not expand or build new medical schools until our GME slots are at least 105 percent of our undergraduate slots," she said.

Texas is a net exporter of medical graduates because other large states offer far more residency positions per capita. According to 2009 data from the Association of American Medical Colleges, New York ranks first out of the 50 states in total residency slots and residents per capita, with 15,679 slots and 80.4 residents per 100,000 population. Texas, meanwhile, had 6,924 residency slots, ranking 23rd out of 50, with 28.5 residents per 100,000 population.

Other large states that ranked higher than Texas included Pennsylvania, which ranked fourth, and Ohio, which ranked eighth. California and Florida ranked below Texas in residents per capita, even though California offered far more residency slots, at 9,214 positions.

Correcting a Mistake

But lawmakers took a step in the wrong direction in 2011 when they slashed funding for GME. The legislature cut formula funding to state health-related institutions that support GME faculty costs and development of new GME positions from $6,653 per resident per year to $4,436. That's $25 million less for 2012-13. It also cut funding for the Texas Higher Education Coordinating Board's Family Practice Residency Program from $21.2 million for fiscal years 2011 and 2012 to $5.6 million for the next two years.

Lawmakers also slashed to the bone two physician education loan repayment programs designed to encourage doctors to practice in underserved areas and see Medicaid patients.

Representative Kolkhorst says the GME cuts were unfortunate but necessary given the state's fiscal situation in 2011.

"I don't think anyone supported the cuts we made to either GME funding or the physician loan repayment program; however, they were necessary with the huge economic downturn our nation and state experienced beginning in 2008," she said. "Additionally in 2010, the electorate spoke loudly and demanded that the legislature figure out a way for the state to live within its means during this economic downturn."

Representative Kolkhorst is optimistic lawmakers can restore some of those funds in 2013, but Representative Zerwas says that also could be a tough session as far as the budget goes.

"But with regard to funding GME, we simply have to prioritize that as one of our areas of importance," he said. "If we don't do that, then the whole effort to increase the number of medical students and medical graduates is for naught."

Relying on Physician Extenders

The question of what role physician extenders, such as nurse practitioners and physician assistants, should play in increasing access to primary care likely will be a thorny one. Over the past three sessions, nurse practitioners sought legislative approval to diagnosis and prescribe independently without physician supervision. In fact, there were three separate bills in the 2011 session on that topic.

House Bill 708 by Rep. Kelly Hancock (R-North Richland Hills) would have allowed nurse practitioners, nurse anesthetists, and clinical nurse specialists to prescribe, diagnose, order, and prescribe therapeutic care independently of physician supervision. House Bill 915 by Rep. Wayne Christian (R-Center) would have given advanced practice nurses the authority to prescribe, diagnose, order, and prescribe therapeutic care. Both bills would have placed authority for policing those activities under the Texas Board of Nursing.

House Bill 1266 by Garnet Coleman (D-Houston) would have expanded the scope of practice for advanced practice nurses to include advanced assessment, diagnosing, prescribing, and ordering.

TMA defeated all of those measures, but the interim charge gives the advanced practice nurses another shot to sway lawmakers to their point of view.

Representative Zerwas says taking another look at this issue in a setting where there is less political pressure than in the midst of a legislative session is fine, but lawmakers already have given a "great deal of consideration" to it.

"My sense is that expanding the role and authority of midlevel providers does not necessarily enhance the access problems that we realize out in some of our medically underserved areas," he said, adding that nurse practitioners are likely to migrate to where the money is, not the rural areas. "So I don't think we're necessarily going to solve any access issues in that regard. At the same time, what we'll do is decrease the potential quality and safety that we want in our health care providers."

Representative Kolkhorst says she worked with the advanced practice nurses, TMA, and others during the 2011 session to find a way to better allow advanced practice nurses to provide care within the scope of their education and training. Unfortunately, she says, those efforts failed to find common ground.

"While I do accept that data from other states show that APNs [advanced practice nurses] are practicing independently, the fact remains, however, that every state is different, and Texas, for instance, has been moving more towards a collaborative and integrative health care model," she said. "Such examples are physician-led institutions like Scott and White and others leading the way on coordinated care and integration."

Dr. Floyd says physicians recognize nurse practitioners and other physician extenders as "integral players" in health care delivery but adds the emphasis should be on developing health care delivery teams under the leadership of physicians. Such teams could use nurse practitioners for routine follow-up visits and nurse call systems, and social workers or resource coordinators working with the physician to allow the doctor to focus on more complex medical issues.

"If you can use physicians in that way, then it will spread the physician out to be able to cover many more patients," he said. "We need physicians to be leaders of the team. There certainly is a role for midlevel practitioners but when it comes to independent practice I certainly don't believe they have the foundation to lead that team that's trying to manage a population. They just do not have the foundation, the education, the experience, or the skills to do that."

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

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