Feeding the Physician Pipeline
By Amy Lynn Sorrel Texas Medicine November 2013

TMA Forum Promotes GME Expansion
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Medical Education Feature — November 2013

Tex Med. 2013;109(11):37-40.

By Amy Lynn Sorrel
Associate Editor

After the 2013 Texas Legislature answered the Texas Medical Association's call for more funding for graduate medical education (GME), TMA wasted no time making sure the money gets put into action. 

In late August, the medical association joined the Texas Hospital Association and the Texas Higher Education Coordinating Board (THECB) to host a forum to help nonteaching hospitals, medical schools, and other entities take advantage of the nearly $2 million in planning grants that lawmakers authorized for new, first-year medical residency positions. 
TMA officials say the legislative investment marks critical progress toward addressing the bottleneck Texas faces in physician training as medical school enrollments outpace the number of entry-level residency training slots available. A 2012 report by THECB estimated that at least 63 Texas medical school graduates would not find an entry-level residency slot in Texas in 2014. That number jumps to 180 students in 2016.  
Because hospitals play a critical role in opening new training spots, lawmakers designated the planning grants specifically for those entities that have never operated a GME program and are therefore eligible for additional federal funding. 
"We've been talking about this [capacity] problem for years, and now we're excited about the opportunity to do something about it," said David Coultas, MD, a member of TMA's Council on Medical Education. 
Hospital representatives say they, too, are well aware of the problem and are willing partners in the solution. 
At the time this article was written, hospitals and medical schools were under pressure to meet the Nov. 15 application deadline for the two-year, $150,000 planning grants that will allow them to investigate the feasibility of opening first-year residency programs. THECB officials say it was difficult to know just how many hospitals qualify, but it will announce up to 12 awards by Dec. 15. 
The planning grants are one component of an overall $30 million increase in state funding the legislature approved for GME for the 2014-15 biennium through the budget and two other bills, House bills 1025 and 2550. Of that amount, $14 million is dedicated to a new GME expansion strategy that includes the planning grants, money for existing but unfilled residency slots, and funding to expand existing GME programs. 
Because building a GME program from scratch is labor-intensive, however, TMA's Council on Medical Education organized a forum of state and national experts to educate and share resources with hospitals that are new to the concept and likely need academic partners to get residency programs off the ground. View the presentations at www.texmed.org/gmeForum. 

GME Bottleneck

The confluence of health care reform and an exponential growth in the Texas population makes feeding the physician pipeline more critical than ever. Based on the current trajectory of medical school enrollments, however, "if every graduate wanted to stay in Texas, the state could not accommodate them," TMA Council on Medical Education Chair David Wright, MD, said. 
That's largely because Texas medical schools already have met the Association of American Medical Colleges' (AAMC's) goal of increasing enrollments 30 percent by 2015, and the number of active residents and fellows has grown 15 percent since 2000. But the number of available residency slots lags, while Texas still ranks near the bottom at 43rd in the state ranking of patient care physicians per 100,000 population. 
"Physician shortages will worsen if we don't increase GME training slots, and Texas already has a physician shortage," said Susan Cox, MD, regional dean for the UT Southwestern Medical Center in Austin. 
Lawmakers heard that message.
Senate Finance Chair Tommy Williams (R-The Woodlands) says the shortfall in GME slots forces many Texas medical graduates to leave the state and not return. "When that happens, we lose the four-year investment we make in medical students," which costs at least $170,000 per student, according to TMA data.
For the first time, Senator Williams says, the legislature provided seed money to encourage hospitals to become teaching grounds for new residents, recognizing that it can take years. Once hospitals achieve that status, they can leverage additional Medicare dollars to continue the residency programs in hopes of retaining homegrown medical school graduates and ultimately addressing growing physician shortages.
The approach, first proposed by The University of Texas System and backed by TMA, helps overcome certain hurdles within federal rules for GME funding. TMA's forum sought to help nonteaching hospitals understand Medicare GME funding rules so they could become eligible for those additional dollars. 
To contain costs, Congress in 1997 imposed a limit on the number of residency positions the Medicare program will fund, explained AAMC Director of Hospital and GME Payment Policies Lori Mihalich-Levin. Congress did not, however, prohibit hospitals that were not training residents as of 1996 from becoming new teaching hospitals reimbursed by Medicare. A new teaching hospital may also establish a resident cap.
"Congress has no desire to pay additional money for anything right now, and GME is no exception," Ms. Mihalich-Levin said, applauding Texas' attempt to do something about it. 

Starting From Scratch

The planning grants are meant to help hospitals and other eligible entities determine the feasibility of establishing a GME program. They will examine financial viability and availability of teaching faculty, for example, to determine the type of residency program that could be offered based on Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) standards. 
Because starting from scratch is not easy, the extra money will come in handy, Dr. Coultas says, adding that the effort is worthwhile. 
The pulmonologist and vice president for clinical and academic affairs at UT Health Northeast, the clinical arm of UT Health Science Center at Tyler, helped launch an internal medicine residency training program with Good Shepherd Medical Center in Longview in 2012. By opening up 18 residency slots, the program helps fill an important need in the rural and largely underserved area with a high Medicaid population and a growing number of retirees. It received more than 1,000 applications for those residency positions, "so there is a huge demand out there among Texas graduates, too," Dr. Coultas said. 
An internal medicine residency program can cost between $100,000 and $130,000 per resident per year, and sustaining program costs is a valid concern, UT representatives acknowledge. But the programs aren't meant to be moneymakers, and with Medicare funding, the Good Shepherd program breaks even. Besides cultivating future physicians, a residency program has other benefits. It can save on recruitment and placement costs, expand primary care access inexpensively, and keep doctors whom patients are familiar with in the area. 
As with the UT-Good Shepherd program, experts say the new planning efforts likely will require partnerships among hospitals and ACGME- or AOA-accredited sponsors like academic centers with the know-how on fulfilling ongoing accreditation, as well as the faculty and administrative resources to more quickly launch a GME program.
In Sulphur Springs, Hopkins County Memorial Hospital Chief Executive Officer Michael McAndrew searches for creative ways to partner with an academic institution or other hospital districts to take advantage of the grants and get more physicians to the rural area. 
"Where we are, our philosophy is that we have to grow our own," he said. "I would dearly love to have some kind of family or internal medicine residency program. I never saw this as a way to make money, certainly. But the very people who can put these [planning grants] to use are those with the most limited resources."
Recruiting has always been difficult for the hospital, which started its own nontraditional nursing program to develop nurses and now sees the fruits of that program. He sees the planning grants as an opportunity to do the same kind of thing to do more than just get doctors to Hopkins County. 
"If we graduate three doctors a year, we may not be able to keep them all. But those are three doctors who could potentially relocate here to East Texas, and a rising tide lifts all boats. And I see this as an opportunity to really help elevate the level of health care in the region by doing that," Mr. McAndrew said. "But if we can't even get them here, we have no shot at them. If we bring them here, and they are here for three years, we've got a really good shot at them."

Long-Term Commitment

Hospital and academic representatives also raised concerns about the short-term, two-year grants because residency programs can take at least that many years to be established under current ACGME and AOA rules. The grant process itself also is complex. 
The grants are "one possible way of enticing hospitals into the GME teaching business, and it's a wonderful mission for hospitals to take on, and we are hoping a lot do. We will not be turning down any money, certainly. But it's a tall order," said Lois L. Bready, MD, associate dean at UT Health Science Center-San Antonio. Her school was exploring partnerships for the planning grants, and she agrees the faster track is for community hospitals to work with an existing sponsoring institution to determine the feasibility of a GME program. 
But that's just step one. Creating a fully functioning residency program requires an ongoing commitment not just from hospitals and medical schools, but also from the legislature, Dr. Bready says. "I look forward to next session and fervently hope this forward motion continues and grows to take it to fruition."
According to THECB Workforce Director Suzanne Pickens, "legislative staff indicated to us that this is a long-term program, and [funding] will continue. There are no guarantees, but that's what was made clear to us." 
Still, board staff acknowledged that the labor-intensive process of applying for the planning grants and the quick deadline, as well as cost concerns, could present some hurdles. They promised to work with applicants to help ensure the grant awards are exhausted. "We would be thrilled to give out 12 awards," Ms. Pickens said. 
For more information on all of the 2013 GME grant programs, click here or contact Ms. Pickens at (512) 427-6240 or by email.  
Meanwhile, lawmakers are watching closely. "The legislature made substantial new investments in graduate medical education this session, and I would like to see that funding continued if those investments show promise of growing GME," Senator Williams said.

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

Family Medicine Residency Funding Gets a Boost
The 2013 legislature more than doubled funding for the Family Medicine Residency Program from $5.6 million in the last biennium to $12.78 million in 2014-15. The Texas Higher Education Coordinating Board recently approved funding for 716 family medicine residents at $8,760 each per year for 2014-15, compared with 693 residents at $3,968 each per year for 2012-13, when funding was drastically cut. In 2010-11, the state put $21.2 million into the program.
This time around, the state also will set aside $236,000 to pay for 56 optional rural rotations for family medicine residents. Another $6,000 will fund three public health rotations, which would restore the public health rotations cut in the current state budget. 
TMA officials say both rotations expose family medicine residents to medicine in rural or public health settings — two areas that need more physicians.  

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May 13, 2016

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