Keeping Them Home

TMA, Partners Win GME Funding Restoration  

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Medical Education Feature - August 2007  


By  Ken Ortolon
Senior Editor  

More than 40 percent of Texas medical school graduates currently leave the state for their residency training. Many never return. That prompted lawmakers this year to listen to physicians, medical students, teaching hospitals, and others and pump millions of new dollars into medical school budgets to create new residency slots that will keep Texas medical graduates at home.

The legislature approved nearly $35 million in new graduate medical education (GME) funding for 2008-09, boosting total state GME spending to nearly $86 million. The new funds will go to the state's medical schools to pay faculty salaries for those who teach residents, as well as to create new residency slots.

"The ultimate goal here is to significantly increase the number of residents being trained in a state that is very short of medical residencies, particularly in comparison to the number of medical students we graduate," said Kenneth I. Shine, MD, executive vice chancellor for health affairs for The University of Texas System. "We anticipate that we are going to see both an increase in the number of residents and some new programs, particularly in areas such as emergency medicine where we're woefully short of training positions for residents in the state." 

Putting Consensus to Work  

Lawmakers budgeted nearly $63 million in funding that will go directly to medical schools to support residency training. That's up from $25 million in GME formula funding approved in 2005, the first year lawmakers provided formula funding for GME.

In addition, lawmakers appropriated $23 million for three primary care residency programs operated by the Texas Higher Education Coordinating Board. That's down slightly from the previous biennium because lawmakers transferred about $3 million that previously went to the Coordinating Board into formula funding.

The $63 million in formula funds will be divided among eight medical schools, M.D. Anderson Cancer Center, and UT Health Center at Tyler.

Increasing state GME funding was a major priority for the Texas Medical Association and medical education stakeholders this year. A consensus statement developed before the legislative session by TMA, the medical schools, and organizations representing teaching hospitals urged the state to earmark $16,000 per residency slot. While total appropriations fell short of that mark, stakeholders say their united front played a key role in convincing the legislature to increase their investment in residency programs.

"My personal sense in talking with people during the session was that there was clearly an increased awareness of the problem for both training more medical students and more residents, and that there was an increasing understanding of the discrepancy between the number of residents we educate, the number of medical students we provide, and the needs of the state," Dr. Shine said.

State Rep. Lois Kolkhorst (R-Brenham) was a staunch advocate for increased GME funding in the House Appropriations Committee. She says it simply does not make sense that Texas should spend money to produce new physicians only to have them leave the state for their residencies.

"Texas has a shortage of doctors, so why would we allow our doctors to leave the state rather than to create more residency spots and keep them here," she said. "Instead of remaining a donor state, we're trying to keep as many as we can of our undergraduate medical students here in Texas doing their residency so that they can hopefully stay in Texas and practice and help us reduce the shortage that we see forthcoming in two or three years." 

Boosting Slots  

While legislators want the money used to pay faculty salaries and increase residency slots, the medical schools have some discretion over exactly how the money will be spent. So it is unclear how many new slots might be created.

Representative Kolkhorst said there was considerable debate in a House-Senate budget conference committee about whether a general appropriation to the schools would increase residency slots or whether the legislature should do "incentive funding" to ensure that new slots are created.

"I contend that funding the slots they currently have will create a financial picture that will allow our institutions to create more slots," she said.

Still, some medical educators worry that lawmakers may cut future GME funding if the medical schools don't create enough new slots.

So, Dr. Shine has asked the various UT System campuses to submit plans by Sept. 1 detailing which existing residency programs might be expanded, as well as new programs that might be created.

"I think that if we can demonstrate that the investment significantly increases the number of physicians [being trained], the legislature's likely to be responsive to continue to increase that funding," he said.

While lawmakers increased GME funding for the medical schools, teaching hospitals got no money to help them with their residency program costs. In 2003, lawmakers cut all GME funding out of the Medicaid program. Those funds, which went directly to the teaching hospitals, were estimated to be about $126 million.

TMA and the other stakeholders who signed the consensus statement fought unsuccessfully to restore those funds.

"We strongly supported the reinstatement of some of that Medicaid money because it drew down federal money in the order of $1.50 per $1 of state money spent," Dr. Shine said.

Representative Kolkhorst said she and other lawmakers favored keeping all GME funds in the education section of the budget rather than splitting some out into the health and human services budget.

"I don't like to see funding mechanisms sprinkled through several different articles," she said. "I like it consolidated in one place so future legislatures can go to one spot and say this is where we're funding GME."

Dr. Shine says some of the teaching hospitals have made up for the loss of Medicaid funding through use of upper payment limit funds to support their residency programs. "But there's still room for increasing the amount of Medicaid monies in support of residents, and there are active negotiations going on with the Texas Health and Human Services Commission to try 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 at Ken Ortolon.  

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