Cover Story - March 2007
Texas will run out of doctors to meet the demands of a growing and aging population over the next few decades, unless the state trains more physicians and keeps more of them practicing here. But to do that, Texas must stop the exodus of new medical school graduates to other states that offer more residency slots.
"When one looks at the demographics of Texas - mainly our growth rate and the number of physicians coming into this state - there will be without question in the next 10 years a physician shortage, particularly in primary care," said Texas Medical Association President Ladon W. Homer, MD.
To avert a shortage, TMA and the state's medical educators believe lawmakers must commit more money to beef up medical school enrollment and create more residency slots for Texas medical graduates.
That's why TMA gathered together all of the state's medical schools, as well as several organizations representing teaching hospitals and residency programs, to develop a united agenda to take to the Texas Legislature this year (see "Medical Education Priorities"). The group hopes having the medical education institutions back a single set of legislative priorities, instead of pushing competing agendas as they have done in the past, will help convince lawmakers to fund critically needed expansion of medical school enrollments and graduate medical education (GME) programs.
"We think this concept of presenting the consensus needs in a prioritized fashion will help lawmakers be focused on those issues," said Dennis Dove, MD, chair of TMA's Council on Medical Education. "It hopefully will make a bigger statement if all of our medical schools in Texas are saying these are some real prioritized needs for us in educating a future physician workforce sufficient to meet the needs of the state."
When TMA convened a summit of medical school and residency program representatives in Austin in October, it marked what some call an unprecedented effort to unify the state's medical educators behind a single set of legislative priorities.
Dr. Dove, who cochaired the summit with Dr. Homer, says in past legislative sessions the medical schools "were almost in a dogfight" with each other trying to promote their own priorities to the legislature.
"There are needs that are unique to each institution, and the schools recognize that," said Dr. Dove, who also is professor and regional chair of the Department of Surgery at Texas Tech University Health Sciences Center in Amarillo. "But there are some commonalities that clearly are not unique and are the same across the board for all of the schools."
There was lengthy discussion about a wide range of issues at the summit, but Kenneth Shine, MD, executive vice chancellor for health affairs at The University of Texas System, says "it didn't take a great deal of negotiation or discussion" to arrive at some consensus priorities.
"The developing evidence about the physician shortage in the state, the importance of graduate medical education, and the need to strengthen the programs in medical education have never been more compelling and convincing to all of the schools," he said, adding that "identifying and agreeing on these is a major step forward."
Following the summit, TMA staff drafted a statement outlining medical education and physician workforce legislative and funding priorities to which the participants had agreed. As the 2007 legislative session convened in January, virtually all of the participants had signed the document, including all of the state's medical schools and medical education institutions, the UT System, TMA, the Children's Hospital Association of Texas, the Texas Association of Public and Non-Profit Hospitals, and the Texas Association of Voluntary Hospitals.
The document is posted on the TMA Web site at www.texmed.org/consensus.
A Three-Legged Stool
At the top of the consensus agenda is what the group called its "three-legged stool": restoring Medicaid GME funding cut four years ago, establishing adequate formula funding for both GME and undergraduate medical education, and establishing funding to allow needed GME growth.
"A multipronged approach is required to sustain current medical education programs and fund needed growth," the consensus statement said. "It is critical that undergraduate and graduate medical education both be adequately funded. Both levels of education are required to produce a practicing physician. Increasingly, medical schools and teaching hospitals are unable to cost-shift to cover these education costs in response to state funding shortfalls."
State undergraduate medical education funding currently is 7 percent below 2003 levels, while GME funding is down 60 percent. The group estimates that between $64 million and $90 million per year will be needed to restore the Medicaid GME funding cut in 2003. Medicaid GME funding was cut as lawmakers sought to overcome a multibillion-dollar deficit.
Stakeholders also hope to get up to $16,000 per resident to fund GME programs. In 2005, lawmakers actually approved formula funding for GME for the first time, but allocated only $25 million out of $96 million requested.
Dr. Homer says state funding for more residency slots is critical because Texas already is losing graduates to other states that provide more residency opportunities.
"We graduate some 1,250 medical students a year in this state at an expense of about $200,000 to one-quarter of a million dollars per student," he said. "We have about 1,350 residency slots. You'll never get a direct one-to-one filling of all these slots, so many of the students go to states that have more graduate medical education, mainly California, New York, Illinois, places like that."
A survey by TMA and medical schools showed 38 percent of the residents leaving Texas would have preferred to stay here for GME. That represents a combined loss of $27.4 million to the state from the investment in the residents' medical education.
It simply "doesn't make any sense financially" to spend $200,000 training a doctor who then leaves Texas for a residency program and never returns, Dr. Homer added.
Dr. Shine says increasing residency slots and keeping Texas medical graduates practicing here "is a very efficient way to try to increase the number of physicians in the state" and solve the physician shortage problem.
There are other reasons the number of GME slots must increase, he says.
First, many Texas medical schools are expanding their class sizes. The Texas A&M University System Health Science Center, for example, has proposed boosting its enrollment over the next several years from the current 80 students per freshman class to 200. And, Texas Tech University Health Sciences Center also wants to expand its El Paso campus to a full four-year medical school.
"We have an inadequate number of residencies compared with other states and, as a consequence, 47 percent of our graduating medical students go out of state for their residency," Dr. Shine said. Larger class sizes at A&M and other schools "will exaggerate the discrepancy."
Second, additional residency slots would be "extremely valuable" in caring for underserved populations, Dr. Shine says. He supports tying additional state funding for more residency slots to the residents participating in community-based ambulatory care.
Chinks in the Armor?
While virtually all of the state's medical education institutions signed the consensus report, there is some concern the recommendations focus too heavily on GME, at the expense of funding for medical school enrollment expansion.
"I have some concerns about the legislative priorities because they only address GME," said Nancy W. Dickey, MD, president of the Texas A&M University System Health Science Center and vice chancellor for health affairs of the A&M system. "We're attempting to expand our medical school in response to exactly the same issues this group addressed. The priorities do not address whether we should be expanding Texas medical schools."
In fact, participants at the October summit did discuss the need for medical school expansion and unanimously concluded that medical school enrollment needs to grow. However, they stopped short of endorsing a specific target for medical school growth in Texas. Participants felt they first needed to better understand how much enrollments have already grown and the state's capacity for additional growth before endorsing expansion.
Thus, the group charged TMA with surveying the individual schools and the Texas Medical and Dental Schools Application Service to estimate the capacity for growth. The study will take into account expected patient caseloads, available faculty, training sites, accreditation requirements, and a high-quality applicant pool. That survey has been conducted, and results were being analyzed by TMA staff in January. Both the Council on Medical Education and the Committee on Physician Distribution and Health Care Access were expected to review the results during TMA's Winter Conference in February.
"Texas should strive to achieve a physician workforce that is closer to the national average for physicians per 100,000 population (an increase from 186 to 230 physicians per 100,000 population)," the consensus document concluded. "Enrollments bear continued monitoring for possible adjustments should changes occur in future state workforce needs."
One of the questions the group hopes TMA's survey will answer is whether enrollment could increase 20 percent, or even 30 percent, and still maintain the same quality of applicant.
Increasing the Investment
The consensus document made several other recommendations. The group urged lawmakers to provide funding for debt service on tuition revenue bonds; full funding for the Joint Admission Medical Program (JAMP), which guarantees medical school admission to economically disadvantage students who fulfill certain educational requirements; and funding for infrastructure needs, such as libraries, classrooms, utility costs, and others.
The report also recommends lawmakers expand the state Physician Education Loan Repayment Program to improve the geographic distribution of physicians throughout the state, and enlarge nursing educational opportunities to train more bedside nurses. Summit participants believe expanding the loan repayment program would help more physicians deal with mounting education-related debt and offer incentives for physicians to practice in underserved areas.
Dr. Shine says funding for the tuition revenue bonds, which back capital expansion products on state university campuses, is critical for all of higher education, including the medical schools.
"The investment in facilities is absolutely essential if we are going to be able to expand or even maintain our research leadership and to deal with an increased number of students, as well as explore new research opportunities," he said. "Without that kind of long-term investment, we're in serious trouble."
Dr. Shine also says the JAMP funding, which would amount to only $10 million for the biennium, could have a significant impact on training a more diverse physician workforce. Among the last group of 65 JAMP students admitted to medical schools in Texas, 38 percent were Hispanics and 10 percent were African-American, he says. "On average, African-Americans make up only about 3 percent of medical students in the state, so a 10-percent ratio of African-Americans is a very hopeful ratio."
Delivering the Message
With the bulk of the medical education community on board, TMA and its allies delivered the report to Gov. Rick Perry, Lt. Gov. David Dewhurst, and key House and Senate leaders in January. Dr. Homer is optimistic the report and the united stance of the medical education institutions will provide the clout needed to push the funding recommendations through the legislature.
"The lieutenant governor's office and the governor's office both are aware of this effort and both have, in fact, been impressed that the medical schools are coming together on these issues of what they really need in Texas to supply us an adequate number of physicians," Dr. Homer said.
State Rep. Dan Branch (R-Dallas), who sits on the House Appropriations Committee and who chaired an interim study on GME before the last session, says he supports the consensus recommendations. However, he says it is too soon to venture a guess on how well received they will be by legislative budget writers.
"The crystal ball is always a little bit cloudy at the beginning of the session," Representative Branch said. "The good news is that we have somewhat of a surplus. Perhaps that creates hope that we might be able to convince other legislators of the importance of these issues and that they would prioritize them in a way that we would get some enhanced funding."
State Comptroller Susan Combs has estimated the surplus at more than $14 billion, but many issues will compete for a share of that money, and a constitutionally mandated spending cap may restrict use of some of those surplus funds.
"These are real important issues," Representative Branch said. "What the session will determine is how they stack up against some of the other real important issues facing the state. The health care community is going to have to be effective in communicating how important some of these issues are to the future of Texas. The more effective we are in making that case, the higher likelihood that someone will say we have to prioritize this."
Having a coordinated message and all the stakeholders on board will help, he says. "The key now is to deliver the message and drive it home. You've got to deliver it more than once and engage people early and often with the right spokespeople and in a concerted and consistent and repeated effort so it finally sinks in."
Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or email Ken Ortolon.
Texas Physician Workforce Growing, But Not Fast Enough
The number of physicians practicing in Texas has grown since 1995, but Texas still lags well behind the national average for physicians per 100,000 population.
And the state will need to train more physicians or attract more out-of-state and international medical graduates (IMGs) if it is to meet the health care needs of a growing and aging population.
In a presentation to the TMA Committee on Physician Distribution and Health Care Access in September, Woody Kageler, MD, said the total physician workforce in Texas rose by 39 percent and the number of primary care physicians increased by almost 5,000, or 46 percent, between 1995 and 2005. Those figures were based on a TMA analysis of data from the Texas Department of State Health Services.
The Texas Medical Board also reported a 35-percent increase in the number of medical license applications in 2006, as well as the fifth highest number of newly licensed physicians and a record number of newly licensed IMGs since 1981.
Despite those increases, Dr. Kageler, who chairs the TMA Committee on Physician Distribution and Health Care Access, says Texas still relies on other states and countries for new physicians.
Texas trails the national average for physicians per 100,000 population. The state currently has 186 physicians per 100,000 residents, while the national average is 230. Texas has the lowest physician-population ratio among the six most populous states. (See "We're No. 6.")
The American Academy of Family Physicians (AAFP) predicts serious shortages of primary care physicians in five states, including Texas, and says all states will have some level of family physician shortage by 2020. Those shortages are being driven, AAFP says, by population growth, increased numbers of elderly residents, and a more than 50-percent drop in medical graduates entering family medicine since 1997.
TMA supports a number of initiatives to foster physician workforce retention and growth. They include increased medical school enrollment, adequate state and federal funding for both undergraduate and graduate medical education, practice incentives for medically underserved areas, restoration of Medicaid GME funding cut in 2003, and an increase in residency slots in Texas.
Medical Education Priorities
TMA and the state's medical education entities have reached consensus on the priorities for the 2007 legislative session. The key elements are:
- Restoring Medicaid graduate medical education (GME) funding;
- Adequate formula funding for GME ($16,000 per resident) and undergraduate medical education (restoration of 2003 cuts and additional funding to allow for necessary growth);
- Funding to allow needed GME growth;
- Funding of debt service for tuition revenue bonds;
- Full funding for the Joint Admission Medical Program;
- Funding needed for infrastructure support (adequate educational space, libraries, utility costs, and others) at health-related institutions;
- Removing the tie between Medicaid GME allocations and Medicare-funded GME caps;
- Substantial expansion of the Physician Education Loan Repayment Program to improve geographic distribution of physicians; and
- Expansion of nursing education opportunities.
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We're No. 6
Here's how the six most populous states rank in the number of physicians per 100,000 residents:
1. New York - 330
2. Pennsylvania - 255
3. Illinois - 241
4. California - 227
5. Florida - 217
6. Texas - 186
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