Medical Education - November 2008
Tex Med . 2008;104(11):53-55.
By Ken Ortolon
Although an influential lawmaker says the state would be "penny wise and pound foolish" not to spend more money to create new graduate medical education (GME) opportunities for Texas medical graduates, convincing legislators of that may not be easy.
State Rep. Dan Branch (R-Dallas) and medical education leaders from across the state agree that getting additional state funds for GME in next year's legislative session will be a tough task because of a sour national economy and some pushback from lawmakers who approved nearly $63 million in formula funding for residency training just two years ago.
"We need more slots," Representative Branch, a member of the House Appropriations Committee and chair of a Select Committee on Higher and Public Education Finance, told participants at the third Medical Education Summit, hosted by the Texas Medical Association. "It seems to me at a time when Texas has a strong economy, has a really good tort system in place that promotes practicing medicine vis-à-vis some other places, and is sort of a hot spot as a growing southwestern state, this is the time that we should get some GME slots."
Representative Branch says increasing residency slots in Texas will not only help the state keep its own medical graduates at home, but also help "import some of the best and brightest from some of the outstanding medical schools across the country."
Medical educators who attended the summit, held in conjunction with TMA's Fall Conference in September, certainly were glad to hear that message from a lawmaker who wields tremendous influence over funding of health-related institutions. But they recognize they will have to make the case for GME funding against all the other funding priorities the legislature will face.
Nancy W. Dickey, MD, president of the Texas A&M Health Science Center and vice chancellor for health affairs for the Texas A&M University System, says lawmakers next year will face the "constant difficulty of trying to shoehorn" more programs in than there is money to pay for.
"We will have to help prioritize for the good of the state whether those dollars are best spent in health professions education or in other arenas," she said.
TMA leaders and the educators who attended September's summit hope they have made a good start toward accomplishing that goal.
TMA hosted the first medical education summit prior to the 2005 legislative session to get all of the state's medical schools, as well as other stakeholders in the medical education community, to agree on legislative priorities for the upcoming session. That summit, as well as the second one held before the 2007 legislative session, resulted in consensus statements that medical educators took to the legislature, presenting a united front on key medical education issues.
In 2005, lawmakers approved $25 million in state funding for GME, essentially restoring Medicaid GME funding slashed from the budget during a prior session. In 2007, lawmakers approved roughly $63 million in formula funding for GME, totaling about $5,600 per resident in the state.
Michael Ragain, MD, chair of TMA's Council on Medical Education, says this year's summit was an attempt to build on past efforts.
"It's important that we get a jump start on the legislative session now and develop some policy," Dr. Ragain, who also is chair of family medicine at Texas Tech University Health Sciences Center, told summit participants. "In the past we've been able to come to some collective agreement, and it's been effective in the legislature."
Dr. Ragain says stakeholders seem to agree that the biggest challenge facing them is the need to expand the physician workforce. "There are a lot of different bodies that have looked at the workforce and they think we're going to be quite short as the population ages, as the baby boomer curve moves into the older age group, where there is going to be higher utilization of health care resources," he said. "So we're trying to grapple with that. And I think Texas is in a really tight spot in terms of physician workforce. We really need to grow the physician workforce."
Texas has been doing a good job of expanding undergraduate medical education (UME) opportunities by creating a new medical school in El Paso and expanding class sizes at several other institutions. Dr. Dickey says the state is poised to meet an Association of American Medical Colleges recommendation of a 30-percent increase in medical school enrollment before the target date of 2015.
But increases in GME slots in the state have lagged behind UME expansion. Dr. Ragain says that is because funding of UME traditionally has occurred at the state level, where Medicare largely funded GME in the past. Medicare, however, has not funded any new GME slots for several years, meaning states have been forced to pick up the slack.
Expanding GME slots when the number of medical school slots is expanding rapidly is critical, many of the stakeholders say. Otherwise, Texas may be wasting tax dollars on physicians who will end up practicing elsewhere.
In 2007, medical educators asked the legislature for some $16,000 per resident to help meet faculty expenses incurred in existing GME programs. Lawmakers approved roughly a third of that. But some of the stakeholders say some lawmakers may have gotten the wrong message, expecting those funds to produce substantial increases in residency slots in the state. Those lawmakers may be reluctant to put more money into formula funding if they are not convinced it will go into expanded GME slots.
"When we started the discussion about GME funding six years ago, it was presented in terms of needing to get to approximately $16,000 per resident per year because we were in fact cross-utilizing dollars set aside for undergraduate medical education in paying for faculty that were really doing graduate medical education," Dr. Dickey said.
The actual cost of creating new residency slots is around $100,000 per year per slot, she says.
"If we have confused or misinformed our legislators regarding that dollar figure, if they expect that every time they give us an additional $15,000 it's going to turn into a new GME position, the legislature is going to be very unhappy."
Getting the Right Mix
While there appears to be consensus that continued expansion of both undergraduate and graduate medical education opportunities in the state is needed, there seems to be some disagreement over what type of doctors should be trained and where.
"I think we all agree on the need for increased funding in those two areas - UME and GME," Dr. Ragain said. "Where we separate some is that regionally, there are differences in terms of the need for which type of physician or specialty of physician."
He says physicians in San Antonio are concerned about shortages in pediatric subspecialties, while doctors in other parts of the state worry about shortages of primary care physicians and general surgeons.
Texas is below the national average for virtually every specialty, but who decides which specialties are the highest priorities for GME expansion?
Dr. Dickey chairs the Governor's Health Care Policy Council, which is examining that issue and alternate ways to pay for GME. She says one approach is to target those specialties for which large numbers of Texas medical graduates are leaving the state. Right now, emergency medicine, anesthesia, and otolaryngology are among those that top the list.
"We think that probably these things need to be taken into consideration: targeting those specialties for which students are leaving the state and the areas with the biggest demonstrated shortages" Dr. Dickey said. "But you have to put into the mix what hospitals are willing to step up to the plate and help create because hospitals continue to be a major funder of graduate medical education."
John C. Jennings, MD, regional dean of Texas Tech University Health Sciences Center's Permian Basin School of Medicine, says creating GME opportunities in communities where there is a need for more physicians also needs to be considered.
"We tend to congregate our graduates in the state's larger communities, and that's not really where the greatest needs are," he said. "The needs are in the communities of 5,000, 10,000, and 25,000 that have no exposure to medical education training programs."
Dr. Dickey's council also is looking at new ways to finance GME programs. One proposal under consideration is using some of the money generated from physician licensing fees to fund GME. Her panel is to present its recommendations to the governor by Dec. 1.
Stakeholders did not reach consensus on their legislative priorities during the September summit. However, TMA was working on a draft consensus statement it hoped to circulate to the stakeholders this fall. Dr. Ragain says he hopes to have a final statement of legislative priorities approved by all parties well before the legislature convenes in January.
Dr. Dickey says she hopes that the consensus statement will support not only continued funding for UME and GME expansion, but additional funds to meet educational needs in the allied health professions, as well.
"I would very much like to see and expect to see support for expanded GME funding, support to complete the expansion of the medical schools that is in progress, and recognition that we need to support solutions for the whole health care professional team, that there are shortages in all those areas," she said. "I hope to see some recommendation for a process that would put a number of players at the table to make recommendations regarding where the greatest need is for particular specialties. I think it would be appreciated if the profession that is asking for the support would put forth at least some process that would help determine where the greatest needs are and where the greatest leverage needs to be placed."
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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