Recommendations for strengthening primary care in the 83rd Texas Legislature

In preparation for the 83rd Texas Legislature convening in January 2013, the Texas Academy of Family Physicians retained Charles Bell, M.D., former deputy executive commissioner of the Texas Health and Human Services Commission, to develop a series of recommendations to increase the training and production of primary care physicians and improve Texans’ access to primary care. TAFP members then began a legislative education campaign through TAFP’s Key Contacts program to reach out to their elected state officials and advocate for these recommendations.

In the most acute sense, family physicians know the needs of their communities and their patients, and this understanding resonates with their legislators. To learn more about how to get involved as a Key Contact in the 83rd Texas Legislature and educate your elected officials on the grass-roots level, go to www.tafp.org/advocacy or contact Tom Banning at tbanning@tafp.org.

Recommendation 1: Restore funding for Family Medicine Residency Programs through the Texas Higher Education Coordinating Board to the 2010-2011 appropriation level.

Texas’ 28 family medicine residency programs are the lifeblood of the state’s primary care physician workforce, and they give back to their communities by managing primary care clinics that deliver well-coordinated, cost-effective care to populations that need it most. Last session, the Legislature reduced the investment in family medicine residency programs by 73.6 percent, from $21.2 million in 2010-2011 to $5.6 million in 2012-2013. Some temporary stopgap funding has been provided through other organizations, but unless additional state funding is provided, training programs will be forced to reduce the number of residency positions they offer, reduce their training staff, or close their doors altogether.

Recommendation 2: Create new community-based primary care residency training programs by restoring funding to the Texas Higher Education Coordinating Board’s Primary Care Residency Program and Graduate Medical Education Program.

The vast majority of state and federal support for medical residency training goes directly to teaching hospitals and academic health centers, which have budgetary priorities misaligned from the needs of the state. For the most part, primary care is practiced in outpatient clinics, the setting most effective for training primary care physicians. Last session, the Legislature zeroed out funding for two budgetary line items through the Texas Higher Education Coordinating Board intended to support community-based primary care residency training. The Legislature should restore that funding and direct the coordinating board to retool these programs so that they help fund the creation of new residency training programs set in community-based clinics.

Recommendation 3: Restore graduate medical education formula funding appropriated to medical schools to 2010-2011 levels and use the restored funds to provide incentives to medical schools that increase the number of primary care physicians they train.

Medical schools receive a portion of their state appropriation based on the number of medical residents training in their affiliated residency programs through a budgetary line item entitled “graduate medical education.” While this GME formula funding is a significant investment, there currently exists no method for the state to influence what type of physicians are being trained. Last session, each medical school experienced a significant reduction in GME formula funding, cut from $79 million in 2010-2011 to $57 million in 2012-2013. If the state restored funding to 2010-2011 levels, it could use the restored funds to create an incentive pool for those medical schools that increase the number of primary care residents trained in their affiliated residency programs.

Recommendation 4: Require medical schools to spend the full amount of funding appropriated through the GME formula directly in support of residency training.

GME formula funding is appropriated to medical schools based on the number of residents training in residency programs affiliated with the schools. The funding is intended to support the training of residents, but medical schools are not required to show that the funds are actually spent directly on the training of residents. Requiring health-related institutions that receive GME formula funding to spend those funds directly in support of residency training would bring a measure of transparency to bear on how much institutional support residency training programs of different disciplines receive from their sponsoring institutions.

Recommendation 5: Utilize a percentage of total medical school formula funding to create an incentive pool for the development of innovative programs designed to increase the state’s primary care physician workforce.

Some medical schools in Texas are developing programs designed to encourage medical students to pursue careers in primary care by making medical education less expensive, less redundant, and more effective at generating an appropriate physician workforce. Establishing an incentive pool will create competitive pressures on medical schools to develop innovative strategies to make primary care more attractive to students at the critical decision-making moment.

Recommendation 6: Establish an information tracking system at the Texas Higher Education Coordinating Board to track medical students for five years after they complete medical school.

It is relatively simple to count how many medical school graduates enter primary care residencies, but after their third year of training, many residents, in particular those in internal medicine residencies, go on to subspecialty training. To measure the number of medical school graduates who complete training and begin practicing primary care medicine, the state must track those graduates for at least five years after they complete medical school. With this data tracking system in place, the state can accurately determine how successfully state-funded institutions are producing the physician workforce Texas requires and provide incentives to influence this action.

Recommendation 7: Align the Frew Children’s Medicaid Loan Repayment Program and the Physician Education Loan Repayment Program, and restore funding to 2010-2011 levels.

With the average physician graduating from medical school with $160,000 in debt, loan repayment programs provide excellent incentives to recruit those physicians to the most needed medical specialties and to the most underserved communities. In 2009, the Texas Legislature closed a tax loophole for how smokeless tobacco is taxed, generating over $100 million per biennium. Though a portion of those funds were specifically allocated to fund the Physician Education Loan Repayment Program, future funding was zeroed out by the 82nd Legislature. Restoring funding to 2010-2011 levels will again provide an incentive to recruit physicians to the specialties and geographic areas that need them the most.

Recommendation 8: Restore funding for the Texas statewide preceptorship programs through the Texas Higher Education Coordinating Board to the 2010-2011 appropriation level.

Three programs are proven to encourage more medical school graduates to choose the primary care specialties: the General Internal Medicine Statewide Preceptorship Program, the Texas Statewide Family Medicine Preceptorship Program, and the General Pediatric Preceptorship Program. But a series of funding cuts and a complete loss of funds last session have eroded the programs’ capacity and therefore reduced the number of primary care physicians the state can produce. Restoring these programs to their 2010-2011 appropriation will allow them to continue providing much-needed exposure to primary care specialties to encourage bright medical students to enter these fields.

Recommendation 9: Restore funding for the Joint Admission Medical Program through the Texas Higher Education Coordinating Board to the 2010-2011 appropriation level.

Minority physicians have been shown to be more likely to practice in minority or underserved areas, improving access to care and the health status of underserved populations. The Joint Admission Medical Program, or JAMP, supports and encourages highly qualified, economically disadvantaged students to pursue medical education who have not traditionally had ready access to these careers. Last session, funding for the program was cut by 34 percent, from $10.6 million to $7 million, which will reduce enrollment in the program from 150 to 96. Restoring funding to this program through the Texas Higher Education Coordinating Board will improve access to care for underserved populations in Texas.