In its latest issue, Texas Hospitals magazine, a publication of the Texas Hospital Association, featured the following cover story:
Where Have All the Doctors Gone?
The physician shortage in Texas may get worse before it gets better
By Steve Jacob
As the decade unfolds, Texas hospitals may be caught in a physician-shortage vise.
The state faces a wave of newly insured patients seeking care from a stagnant supply of physicians. That wave threatens to crash through the doors of hospital emergency departments when patients cannot get timely appointments.
The primary care workload is expected to increase by nearly 30 percent between 2005 and 2025. A number of factors are feeding this demand, including a growing population; a flood of baby boomers becoming Medicare beneficiaries and acquiring medical conditions as they age; and the influx of newly insured patients under the Patient Protection and Affordable Care Act.
The supply of primary care physicians is expected to rise by only 2-7 percent, however. Three out of four physicians say they already are at or over capacity. The math screams that there will be a crisis of health care access in the next 15 years. Patients can expect longer waits for appointments, shorter physician visits, greater use of nonphysicians for routine care and higher prices.
The physician shortage also will make recruitment of hospitalists and employed physicians in wholly owned hospital subsidiaries that much more difficult, and that may escalate into a bidding war for talent.
The interim charges for the Texas House Committee on Public Health prior to the 2013 legislative session include examining the adequacy of the state's primary care workforce and weighing the impact of an aging population and health care reform as well as the state and federal funding reductions to graduate medical education and physician loan repayment programs. Although the report is not due until this fall, the findings should be obvious: An already inadequate primary care workforce will buckle further under the aforementioned pressures - not to mention the addition of 5 million new Texas residents this decade. GME and physician loan repayment funding cuts will mean Texas will force its medical school graduates to train - and likely settle - elsewhere and lose its investment in their education.
Reform's Rapid Expansion
An estimated 4.5 million Texans will gain health care coverage through PPACA. Medicaid expansion accounted for 1.2 million of these patients. The addition of these newly eligible patients would further exacerbate the current physician shortage.
Texas has 202 physicians per 100,000 residents, compared with the national rate of 257, according to the Centers for Disease Control and Prevention. Texas has fewer physicians than the national average for 36 out of 40 medical specialty groups.
The physician-to-population rate has improved slightly over the past decade because of an influx of out-of-state physicians, aided in part by the 2003 medical malpractice reforms. Those physicians have allowed the state to keep up with population growth. In 2011, about three out of four newly licensed physicians graduated from medical schools outside Texas.
That strategy likely will not be as successful in the future. With health care reform, nearly every state will face primary care physician shortages, and competition to recruit and retain physicians will be fierce nationwide.
A study in the New England Journal of Medicine examined every state's primary care capacity to absorb the Medicaid expansion in 2014.Texas ranked 47th in its ability to accommodate the new beneficiaries because of its current high uninsured rate and low per-capita supply of PCPs. The effect could be more severe in inner-city urban and rural areas, which have far fewer providers than suburban areas.
There were 16,830 PCPs in Texas in 2009. The state had 69 PCPs per 100,000 residents, compared with 81 per 100,000 nationally. Nearly half of all Texas counties are classified as health professional shortage areas, and 29 counties have no PCPs.
Massachusetts reformed its health care system in 2006, giving the nation a glimpse of what is to come when access to health care insurance is expanded without expanding the supply of PCPs. The average wait for a non-urgent appointment with an internist rose from 17 days in 2005 to 48 days in 2011. Fewer than half of family physicians in the state are accepting new patients, compared with 70 percent four years ago. Massachusetts has about 108 PCPs for every 100,000 residents, compared with only about 62 per 100,000 in Texas. This ultimately suggests an even longer wait locally. Massachusetts residents used the ED at a rate 40 percent greater than the rest of the nation.
Tom Banning, chief executive officer and executive vice president of the Texas Academy of Family Physicians, describes Texas' outlook as "Massachusetts on steroids."
"They were hammered with newly insured patients, and their situation will pale in comparison to what Texas potentially faces," Banning said. "This is lost on a lot of our state legislators."
Rural Hospitals Affected Most
Dan Stultz, M.D., FACP, FACHE, president/chief executive officer of the Texas Hospital Association, said physician shortages would affect rural hospitals the most.
"We know historically that rural hospitals already have a more difficult time attracting and retaining physicians," Stultz said. "As the scarcity increases, physicians will become more particular about what they will and will not do, like not covering the ED. Physicians will have more leverage."
The 2011 Legislature did not help matters when it slashed GME funding. State support of the Family Practice Residency Program was cut by 72 percent, from more than $20 million in 2010-11 to $5.6 million in 2012-13. The Texas Higher Education Coordinating Board, which administers program funding, warned that some training programs might be forced to close. In 2000, Texas had 247 first-year family medicine residency positions; by 2011, that number had dropped to 211.
The Primary Care Residency Program was eliminated in 2011. The program trained more than 120 primary care residents. Texas teaching hospitals also are being targeted in deficit reduction plans for a 60 percent cut in a Medicare residency-training subsidy.
The Physician Education Loan Repayment Program, created by the 2009 Legislature, was cut from $23.2 million in 2010-11 to $5.6 million in 2012-13. The budget cut could affect health care access for 1.1 million Texans in underserved areas, according to the Texas Primary Care Office at the Texas Department of State Health Services.
"Almost every area (of Texas) does not have enough doctors. There are significant shortages in multiple specialties across the state," said Darren Whitehurst, vice president of advocacy at the Texas Medical Association. "If we could put 500-600 more doctors in the right places, we could alleviate a lot of the shortages we see today. There are a number of doctors not locating in shortage areas, but the state can help alleviate some of the challenges through state payment policies and issues like loan repayment. The primary payers in rural and border areas are Medicaid and Medicare, and neither is paying the cost for providing care."
In addition, more physicians are reducing the number of patients they see who depend on government insurance for their health care. According to a recent TMA survey, the number of Texas physicians accepting new Medicare patients dropped from 66 percent in 2010 to 58 percent in 2012 and the number accepting new Medicaid patients dropped from 42 percent to 31 percent - an all-time low.
There is a national shortage of medical residencies nationally as well. In 2010, there were about 30,500 medical students competing for some 25,500 residencies. The nation's medical schools - including those in Texas - are on track to increase medical school enrollment 30 percent by 2016, a goal called for by the Association of American Medical Colleges. However, AAMC President and CEO Darrell Kirch, M.D., noted, "This won't amount to a single new doctor in practice without an expansion of residency positions."
Nearly 45 percent of Texas medical school students leave the state for residency training. According to a TMA survey, 38 percent of those students would have preferred to do that training in Texas. Most medical residents set up their practices within 100 miles of their residency location, so the $168,000 the state invests in each student's education on average is lost to another state.
Robert Earley, president/CEO of JPS Health Network in Fort Worth, pointed out that nearly three out of four of his hospital's 202 recent GME graduates stayed in the Dallas-Fort Worth area to practice.
Texas has about one residency position for every medical school graduate, compared with a ratio of 1.7-to-1 in California and more than 3-to-1 in New York. The THECB recommends a ratio of 1.1-to-1. It estimates at least 180 medical school graduates will have to leave the state for their first year of residency training due to a lack of residency positions by 2016.
Banning said medical schools need incentives to produce more PCPs and the state needs to fund more PCP residency slots and restore funding to the Physician Education Loan Repayment Program. He said he is optimistic that the Legislature will address the state's primary care needs.
"The idea of all these new Medicaid recipients accessing the ED where cost is significantly greater than a primary care office visit has some legislators spooked about the budgetary consequences of our lack of primary care access," he said.
Whitehurst said he lumps health care with other pressing state needs.
"Public education, transportation, water - the state needs to prioritize the programs that need to be funded," he said. "Otherwise, we will fall further and further behind. This is not a one-session strategy."
Whitehurst said the Legislature needs to focus on programs such as GME that actually help complete the training for becoming a physician in Texas in addition to state payment policies and loan repayment to help get physicians into underserved communities.
"There is a lot of talk about new medical schools in the Valley, Austin and Fort Worth. We need to make sure that if these programs are created, there are GME opportunities for the students as well. Otherwise, the state will have spent a lot of new money educating these students only to lose them to other states that provide the needed GME programs," he said.
Earley, a former legislator, said the creation of brick-and-mortar medical schools resonates more with lawmakers than GME.
"But we miss out if we don't pair that with GME," Earley said. "That is not a gain for Texas taxpayers. The medical community hasn't effectively gotten that message across. GME cannot continue to suffer cuts. Demand has gone up, and we have not met that demand."
Stultz concurs. He notes that THA and TMA are working together to encourage the Legislature to invest in GME.
"If we get 100 or more slots created, that's a win.
Anything less is a token," Stultz said. "The problem is that
when you realize it's too late to address the physician
shortage, it's really too late. It could take 10 years to fix
it, and the shortage would get worse during that time. I don't
know when we reach that point of disaster, but we may be
getting near it."