Reversing the Threat to Primary Care in Texas

Whereas, A strong primary care base is essential to the comprehensive delivery of healthcare in Texas and the promotion of primary care is vital for medicine and our patients; and

Whereas, Texas faces a current and impending shortage of primary care physicians to meet the health needs of our growing populations; and

Whereas, Texas ranks 45th in the nation in the number of physicians per capita; and

Whereas, The national average for direct-care physicians to every 100,000 people is 220, while Texas averages 152 for every 100,000 people; and

Whereas, 116 of the 264 Texas counties are considered full primary care health professional shortage areas and 60 counties are considered partial health professional shortage areas; and

Whereas, The number of U.S. medical school graduates choosing to enter family medicine and general internal medicine residencies has decreased by almost 50 percent over the past 10 years; and

Whereas, The average medical school graduate debt of more than $100,000 causes many medical students to pass over primary care in favor of more lucrative specialties; and

Whereas, Several recent studies have conclusively shown the effectiveness of primary care physicians in lowering the health care costs and improving overall quality of care; and

Whereas, The deteriorating supply of primary care physicians not only threatens the health of Texas, but has disastrous economic implications as more patients will be forced to rely on expensive, overcrowded emergency rooms to receive basic health care; therefore be it

RESOLVED, That our Texas Medical Association pursue all available means to educate, train, and grow Texas' primary care physician workforce; and be it further

RESOLVED, That our Texas Medical Association advocate increased Graduate Medical Education funding focused on training primary care physicians for Texas; and be it further

RESOLVED, That development of a Debt Forgiveness Program for primary care be explored by the TMA Council on Health Promotion with attention to providing care to underserved areas of our state.

 Relevant TMA Policy

185.001     Texas Physician Workforce . The Texas Medical Association, in its continued study of state and national trends in physician supply and distribution, legislative initiatives at national and state levels, and trends in undergraduate and graduate medical education, came to the following conclusions: There are growing indications of a shortage of certain specialists in Texas and there continues to be an undersupply of primary care physicians in some rural and inner-city areas; minority groups continue to be underrepresented in the physician population; and the majority of physicians practicing in Texas are graduates of out-of-state and foreign medical schools. Therefore, TMA adopted the following:

(1) Continue to focus efforts on resolving the maldistribution of physicians by encouraging physicians to locate in underserved areas of the state.
(6) Recommend that adequate financial support for graduate medical education programs in family practice and other primary care specialties be a funding priority for the state, with emphasis given to residency programs with demonstrated success in preparing physicians for practice in underserved areas.
(9) Support medical school efforts to increase exposure of students to primary care through family practice clerkships and other primary care rotations in medically underserved areas, and recommend that adequate state funding be provided for such programs.
(11) Maintain a structure within the organization to continue to analyze physician workforce data, trace practice location and patterns for Texas medical school graduates, provide workforce data to the TMA, assist medical students in making career choices, assist with placement of physicians in underserved areas of the state, serve as the information resource for appropriate bodies within the association as well as external organizations and institutions, and continue to work with related organizations in evaluation of physician workforce in Texas (Committee on Manpower, pp 98-99, I-90; amended CME Rep. 4-A-01; amended CME Rep. 6-A-03).

185.002     Physician Workforce-Primary Care and Specialty Training . The Texas Medical Association:

(1) Recognizes primary care specialties as family practice, general internal medicine, general pediatrics, and obstetrics/gynecology.
(2) Supports the concept of primary care training in Texas medical schools.
(3) Supports the concept of individual freedom of choice of Texas graduates in choosing careers.
(4) Supports approval of appropriations and adequate funding of the family practice clerkship.
(5) Supports continuing efforts to prepare primary care physicians to meet the state's needs, particularly in rural, border, and inner-city shortage areas. TMA also recognizes the growing specialty shortage and strongly supports efforts to increase access to specialty care in Texas through adequate training opportunities in shortage specialties. To recruit and retain physicians to provide for the state's health care needs and ensure access to care, TMA supports state efforts at tort reform, restoring affordable professional liability premiums, and obtaining higher Medicaid, CHIP, and Medicare provider fees.
(6) Encourages Texas residency training programs to provide opportunities for residents to train in small cities or rural communities during part of their graduate medical education. These opportunities include rural rotations for existing residency training programs, expansion of existing urban-based programs into small city or rural locations, and establishment of new programs in small city or rural locations.
(7) In defining the state's physician workforce needs, the Texas Medical Association recognizes that primary care physicians are an important and vital component of the healthcare delivery system for meeting the state's medical needs. Accordingly, the Texas Medical Association supports medical school efforts to recruit students with an interest in these specialties and to foster that interest on into residency. Further, the Texas Medical Association supports public funding of incentive programs with demonstrated effectiveness in recruiting and retaining physicians in areas with geographic and/or specialty maldistributions (Council on Medical Education, p 95, I-92; amended CME Rep. 6-A-03; amended CME Rep. 2-A-06).

185.006     Physician Workforce and Distribution….

(2) Further study of shortage specialties will be undertaken to determine the need for these specialties as workforce requirements change.
(4) Texas Medical Association opposes imposition of quotas on medical schools to require that Texas graduates practice in specific areas. The association encourages the development and use of admission criteria to take into account the likelihood of students returning to practice in rural and urban underserved areas, in addition to criteria to appraise students' learning and analytical skills, values and attitudes, and contribution to society and a caring profession.
(5) Texas Medical Association supports the premise that all medical schools have the responsibility to provide the appropriate environment that will motivate students to select careers in primary care and underserved areas. Primary care specialties are recognized as family practice, general internal medicine, general pediatrics, and obstetrics/gynecology. TMA supports efforts of medical schools to increase exposure to students to primary care specialties through clerkships, rotations, and preceptorships in ambulatory settings and seek adequate state funding for such programs. Visible primary care role models should be provided for students early and consistently throughout medical school.
(6) Cancellation of all or part of educational loans for students who complete training in Texas and practice in primary care specialties in underserved areas in Texas is supported by the association. In addition, programs for loan repayment, forbearance, tax exemptions and deductions for education loans and stipends, and deferment of interest or eliminating accrual of interest should be continued and enhanced.(Council on Medical Education, p 82 A-93; Committee on Manpower, p 98, A-94; Committee on Physician Distribution and Health Care Access, p 104, I-94; amended CME Rep. 6-A-03).

185.014     Physician Workforce . The Texas Medical Association approved recommendations from 1996 data submitted by the Special Committee on the Texas Physician Workforce:

(1) A state targeted ratio of 50 percent primary care and 50 percent nonprimary care physicians…
(8) The Texas Legislature should fund Texas GME programs that are currently being supported through teaching hospital and medical school funds to cover the state's share of the cost of GME and to replace the lost practice plan funds with general revenue. (Board of Trustees, p 39C, I-96; amended CME Rep. 4-A01).

200.023     Medical Education for Primary Care . Primary care residencies should be established under the assumption that doctors will be given freedom of choice regarding their practice locations. Medical schools should accept responsibility for providing the appropriate environment that will motivate students to select careers in primary care and underserved areas. Members with established practices are encouraged to volunteer time to teaching (Council on Medical Education, p 91, A-94; reaffirmed CME Rep. 4-A-04).

255.002     Primary Care . The Texas Medical Association adopted the following six recommendations from the Special Committee on Primary Care:

(2) That TMA support the statewide preceptor programs in family medicine, internal medicine and pediatrics for undergraduate medical students to encourage students to select primary care careers.
(3) That TMA recommend to the state that it expand the existing Physician Education Loan Repayment Program to increase the number served. Eligible physicians currently receive a maximum of $9,000 per year for a maximum period of five years. These funds may be matched by federal funds up to $9,000 per year, also for a maximum of five years. Program eligibility for the existing program includes full-time practice after completion of residency training at specified state agencies and underserved areas. Each completed year of service is followed by a lump-sum payment.
(4) That TMA support the Medically Underserved Community-State Matching Incentive Program for Primary Care Physicians. The program provides $15,000 to $25,000 per year, to be shared equally by the state and community, to Texas-licensed primary care physicians who agree to establish practices in specified underserved areas for a minimum of two years.
(5) That TMA support the Texas Health Service Corps Program. The program provides up to $15,000 per year to entering primary care residents who agree to practice one year for each year a stipend is received in specified underserved areas after completion of their Texas postgraduate training.
(6) That TMA recommend to the state full funding for the existing family practice residency training programs (Board of Trustees, p 24, I-94; amended CME Rep. 1-A-05; amended CME Rep. 1-A-05).

255.003     Undergraduate Medical Education . Texas Medical Association initiatives for undergraduate medical education include (a) maintaining the preceptorship programs in family medicine, general internal medicine and general pediatrics for undergraduate medical students, (b) funding faculty enhancement program for generalist physicians (Council on Medical Education, p 71, I-96; amended CME Rep. 2-A-06).

185.011     Physician Workforce Long-Term Approach . The Texas Medical Association supports a positive long-term approach to the primary care shortage by encouraging each medical school to increase or maintain its involvement with Area Health Education Centers (Medical Student Section, p 156, A-94; amended CME Rep. 1-A-05).

205.026     Expansion of Medical Student Loan Forgiveness Program :  The Texas Medical Association will seek (1) an increase in the annual state loan repayment amount over the current $9,000 as a way to make the program more appealing to potential applicants, and (2) additional total state funding for loan repayment in order to help alleviate one of the most pressing health care issues, that of access to care (Res. 303-A-06).

205.020     Physician Loan Repayment .  Medical students who complete their training in Texas and who intend to serve in underserved areas of the state should be able to seek cancellation of all or part of their educational loans in return for such service. However, medical students in Texas schools should not be required to serve in underserved areas upon graduation and medical schools should not be forced to participate in programs that mandate their graduates to serve in specific areas (Committee on Manpower, p 124, A89; reaffirmed CME Rep. 5-A00).

205.021     State Loan Repayment Program .  Recognizing the effectiveness of the State Physician Education Loan Repayment Program in recruiting and retaining physicians in underserved areas of the state, the Texas Medical Association supports increased state funding for this program to allow the state to maximize federal matching dollars, to maintain the five-year escalating repayment levels as a retention aid for underserved areas, and to allow for annual growth in the number of physicians receiving loan repayment (CME Rep. 5-I00).

TMA House of Delegates: TexMed 2007