Texas lawmakers invested millions of additional dollars in the 2013 legislative session to address a looming physician shortage. Voters and university regents have rubber-stamped plans to open two new medical schools, in Austin and the Rio Grande Valley. But those moves have not placated the medical community, which remains concerned that Texas has no long-term solution to produce enough physicians, particularly in primary care, to support the surging population.
“Nobody wants to see this pendulum swing, where there’s money for this biennium and no money the next biennium,” said Dr. David Wright, chairman of the Texas Medical Association’s education committee. “There has to be a better, more stabilized funding mechanism for all of this.”
Texas taxpayers already spend $168,000 educating each of the state’s medical students. For graduated medical students, the state will pay $32.8 million to finance nearly 6,500 medical residency positions in 2014-15.
But beginning in 2014, there will be more graduating medical students in Texas than first-year residency slots available in the state, according to a 2012 report by the Texas Higher Education Coordinating Board.
“If they are forced to do their residency training outside of Texas because we don’t have enough slots, they take that investment with them,” said state Sen. Jane Nelson, R-Flower Mound. Nelson filed legislation in the last session to offset that trend by devoting $16 million to expand residency opportunities for graduating medical students at Texas facilities.
The majority of that financing — $12.4 million — will be used to create new first-year residency positions in Texas or fill existing slots that are empty for financial reasons. Nelson’s legislation also sets aside $1.9 million in planning grants to help hospitals that do not have accredited residency programs evaluate what it would take to establish them. There is another $2.1 million in incentives for medical schools to encourage students to go into primary care.
“The message is out to any residency program out there that if you want to grow, you can grow,” said Stacey Silverman, interim assistant commissioner of the Higher Education Coordinating Board, which is charged with distributing the grants. “It’s not a finish line by any standard, but it is an excellent first step, and it gets Texas on the road to solving the physician shortage.”
The nation as a whole is facing a physician shortage. The Association of American Medical Colleges estimates that the United States will have a shortfall of 90,000 physicians within the next decade. The need will be particularly acute in Texas, which in 2010 had 165 physicians per 100,000 people, compared with the national average of 220.
The number of Texas primary care physicians — whose services prevent patients from developing more costly and harmful conditions — is particularly low. Texas does not have enough primary care doctors in 126 of its 254 counties, according to the United States Department of Health and Human Services, which sets a threshold of one for every 3,000 residents. The majority of those counties are rural.
The state’s new grants will mostly benefit hospitals looking to start residency programs from scratch, said Dr. Thomas Blackwell, associate dean of graduate medical education at the University of Texas Medical Branch in Galveston. He said the financing was not enough to encourage most teaching hospitals, including his own, to expand their programs.
“It’s not enough, because remember, it only pays for the first year,” he said. “So who is going to pay for the other years?”
Residency programs last three to eight years, depending on the specialty. The state’s first-year residency grants will provide up to $65,000 per trainee, covering each first-year resident’s salary. But factoring in other costs, like supervisors’ salaries and the expense of extra tests and procedures ordered by doctors-in-training, each position costs about $100,000 to $150,000 a year, Blackwell said.
“You don’t do graduate medical education to make money. Our members are mission-driven,” said Maureen Milligan, president and chief executive of Teaching Hospitals of Texas. Although teaching hospitals come with prestige, advanced medical technology and, in some cases, better health outcomes for patients, Milligan said most residency programs operated at a financial loss for the hospital.
“The challenge is going to be how do you identify new hospitals or other providers that would be willing to get into” graduate medical education, she said.
Most residencies are in urban areas, which have established institutions large enough to support the programs. In addition to the financial burden, rural hospitals often do not have enough patients to ensure residents of performing enough procedures to become accredited. As a result, the state’s rural regions have become increasingly underserved, as doctors are more likely to practice in areas similar to those in which they trained.
While some teaching hospitals encourage residents to team with physicians or clinics in rural areas, Wright said the state should explore expanding residency opportunities to those communities. Silverman said the coordinating board was open to awarding planning grants for hospitals to explore creating networks between providers in rural areas and whether that would provide adequate training opportunity. Ultimately, national accrediting agencies will have to determine whether those networks are sufficient.
While lawmakers may have made progress in the last legislative session addressing the physician shortage, medical providers say the Legislature must still establish consistent, sustainable financing for residency programs. And, they argue, it may need to set up programs with incentives for doctors to train in the specialties needed most.
Wright and Blackwell said Texas should encourage more physicians to go into primary care in rural areas by expanding the loan repayment program, which offers some debt relief to doctors who do so.
“While I understand the concerns of hospitals, I believe that this session they saw the Legislature make funding residency programs a top priority,” Nelson said, “and should trust that we understand how important it is to continue funding them in the future.”