A matter of supply and demand

By Kate McCann

Attention family physicians: Texas needs you. Yes, the U.S. population is increasing—and getting older on average—but as in most things, the problem in Texas is bigger. Texas’ population is outpacing the national growth rate at both ends of the age spectrum: baby boomers are reaching the golden age of 65, while at the same time Texas is growing and importing a younger and poorer demographic.

Former state demographer and current director of the U.S. Census Bureau Steve Murdock, Ph.D., has predicted there will be more than 50 million people in Texas by 2040, 12.5 million of whom will be over 65 years of age. Murdock also expects the number of physician visits to triple as more people require coordinated, ongoing care for chronic diseases like high blood pressure and diabetes. As the demand for health care services increases and the pressure builds for stakeholders to cut costs while improving access, quality and safety in the health system, Texas faces a glaring question: Will there be enough physicians to meet patients’ needs?

The national average for direct-care physicians to every 100,000 people is 220, but Texas averages 157 for every 100,000 people. In primary care, 114 Texas counties are considered full primary care health professional shortage areas and 47 counties are considered partial HPSAs. Twenty-five counties have no physicians.

Texas’ physician shortage is exacerbated in rural and border counties. A recent study in the Journal of Academic Medicine reports that while 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Coming out of residency, physicians tend to gravitate toward large urban and metropolitan areas, leaving rural and border areas with the lowest physician-to-population ratios, especially in primary care.

To access health care services in Odessa, some patients drive as many as five hours from small towns or border areas, says Peter Valenzuela, M.D., M.B.A., assistant dean for clinical affairs and regional chair of the Department of Family Medicine at the Texas Tech University Health Science Center at Permian Basin. Projections for the rural workforce look especially grim given a recent study from the American Association of Medical Colleges that reports only 3 percent of medical students indicate interest in becoming rural physicians.

“If you look at the data, within a population in a large city like Austin, you have plenty of specialists. But if you’re looking at the Permian Basin, when I was president of the county medical society, there were seven doctors who covered a 400-mile radius for 40,000 to 50,000 patients. It kicked the crap out of us.”

Another problem compounding Texas’ primary care shortage is an aging physician workforce. HealthLeaders magazine reports that one out of three practicing physicians in the United States is over the age of 55 and many are expected to retire within 10 to 15 years. A recent Merritt Hawkins & Associates survey gives a more dire prediction: Within the next one to three years, over half of physicians ages 50 to 65 plan to retire, seek non-clinical jobs or otherwise significantly reduce the number of patients they see.

According to Nancy Dickey, M.D., a family physician and current president and vice chancellor for health affairs for the Texas A&M Health Science Center, this means that the current physician shortage could worsen quickly. “We know there are many counties that currently have one or a handful of physicians and we know many of those are relatively senior physicians who are looking at retirement and having great difficulty securing a replacement.”

Because it takes more than a decade to educate and train a physician for practice, medical students and residents in training today will be the ones to step up and replace the retirees. However, the number of U.S. medical school graduates choosing to enter family medicine and general internal medicine residencies has fallen by almost 50 percent since 1997.

Lewis Foxhall, M.D., director of the Statewide Family Medicine Preceptor­ship Program, points largely to students’ financial concerns that make entering primary care specialties less attractive. Graduates leaving medical school carry more than $100,000 of debt on average, and the average income for primary care physicians has dropped by more than 10 percent since 1995 when adjusted for inflation, according to a report by the Center for Studying Health System Change.

“With our current reimbursement system, many of the cognitive specialties as opposed to the procedural specialties tend to not be reimbursed quite as well,” Foxhall says. “Students come out of school, often with very large loans that they’ve accumulated over several years of study, and it makes it more of a barrier for them to consider going into family medicine.”

As Foxhall indicates, students seek higher-paying specialties to pay off educational debt, but the workforce has also seen a shift in mindset as young physicians desire a fair work-life balance and more predictable work hours. This makes so-called “lifestyle specialties”—radiology, ophthalmology, anesthesiology and dermatology—some of the most competitive residency positions in the country.

Roland Goertz, M.D., M.B.A., chief executive officer of the three foundations that oversee all operations of the Waco Family Health Center, sees a generational change and more females in the physician workforce as a driver of more moderate weekly work hours and increased competition for set-schedule specialties. Fifteen years ago physicians would work 70-80 hours a week, but current averages range 40-60. This can be good for a physician’s “perpetuation of life,” but not so good for a system that is most efficient when fewer people do more work, he says. “The problem is not in care or quality. The problem is that the economic model is not built to sustain the drive for ‘I want a balanced life,’ which is what we’ve seen in the last few generations of trainees. Also, females tend to not stay in the workforce as long. That’s just data, not a criticism.”

It is possible to make health system reforms work in an economic model where more people do the same amount of work with the same expectations of income, he adds. “I’m asked if you can provide the medical home with physicians who want a balanced life. I assure you, you can. You have to do it through creative and interconnected ways.”

The Texas Legislature has heard an increasing voice of concern about the health care workforce over the past few years, Dickey says. “As much as six years ago we were talking about the nursing and physician shortages and the volume has been turned up in the last two legislative sessions. Certainly there’s a recognition of shortages nationwide, so health policy gurus have looked at what is laid out in the national shortages and have said, ‘wake up, Texas.’”

Many Texas counties suffer from shortages of all sorts of physicians, including some vital specialties like neurosurgery, rheumatology, endocrinology and at one point, obstetrics-gynecology. “Of course most of us will point to the continuing, on-going, yet-to-be-relieved shortage of family physicians and primary care physicians, which is so important in the medical home model that data suggests would save money and enhance the quality of care,” Dickey says.

In urban areas, patients suffer less from lack of physicians as a whole and more because of a lack of coordination of care and an inadequate primary care network, Goertz says. “You have individuals going from specialist to specialist to specialist without coordination and integration of care, and that’s an extremely expensive system.”

Authors of a study on the Massachusetts physician workforce by the state’s medical society came to a similar conclusion. “Good coordination of care through primary care is essential in order to deliver quality, cost-effective health care.” In April 2006, Massachusetts became the first state to require all of its citizens to carry health insurance. They achieved one goal—the uninsured rate plummeted to just 5 percent of the population and more than 300,000 previously uninsured people came into the health care system—but the health care reform also triggered dramatically rising health care costs as well as increasingly long wait times for patients to see a physician. Patricia A. Sereno, M.D., M.P.H., the immediate past president of the Massachusetts Academy of Family Physicians, told the New York Times in an April 2008 article, “it’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

Implementing the medical home model, which aims to provide all patients with access to comprehensive and continuous primary care, and ensuring that the country will have enough physicians to provide medical homes make up a significant part of AAFP’s 2006 workforce report. AAFP says this will require nearly 140,000 family physicians by 2020—an increase of about 40,000 from 2006 numbers—which is based on achieving a ratio of 41.6 family physicians per 100,000 people.

For Texas to reach this target in 12 years, the state must increase the number of family physicians from the 6,600 Texas had in 2006 to more than 10,000 in 2020, according to the report. For accredited U.S. family medicine residencies, this means expanding program capacity from an average of 21.7 residents to 24 residents to produce the needed 4,500 family physicians per year.

In preparation for the 81st Texas Legislature, which convenes in January 2009, experts have chimed in on solutions for preserving patients’ access to care by utilizing the physician pipeline and encouraging distribution among shortage regions and needed specialties.

At a May 5 hearing at UT Southwestern, members of the Select Committee on Higher and Public Education Finance heard recommendations on graduate medical education, or GME, from representatives of the academic health centers and others. Rep. Dan Branch of Dallas, chair of the select committee, says stakeholders support incentives to physicians and increased funding for residencies, hospitals and medical schools.

The state has an incentive to achieve a return on its investment. “Taxpayers invest over $200,000 per medical student in Texas, so it’s important that we have enough residency slots in primary care and other areas to encourage people to stay in Texas,” Branch says. “There are statistics that show that if you go to medical school here, you do your residency here, you have more than an 80-percent chance of retaining that person as a professional in Texas.”

AAMC recommended increasing U.S. medical school enrollment by 30 percent by 2015 in its 2006 workforce report and at an April hearing of the Texas Health Care Policy Council. Dickey, who chairs the council, says the state must increase the number of medical schools and increase the capacity of existing schools, and Texas is well on its way to reaching the AAMC’s goal due to actions taken by the Legislature. The Texas Higher Education Coordinating Board reported that the eight Texas medical schools graduated more than 1,300 students in 2006-2007, and an additional four-year medical school opening in El Paso in 2009 will boost this number.

“Medical schools are increasing enrollment, but we’re not at this point increasing the number of graduate medical education positions,” says R. Michael Ragain, M.D., chair of the Department of Family and Community Medicine at Texas Tech University Health Science Center. “Sixty to 70 percent of residents will stay within 60 miles of where they trained, so if we train a fine young Texan through medical school who goes off to Washington state, the odds are they’re going to stay in Washington. Then we’ve expended funds to train the students and we lose them because we don’t have the GME slots.”

Branch noted that legislative funding for GME has gone up in the past two biennia, but “we still need to go a long way, so we’ll push for more increases in GME funding and hopefully that will encourage more.”

Proposed incentives for physicians start with strengthening loan repayment programs, which provide financial aid on the back end to physicians who choose to practice for a period of time in medically underserved areas. These types of output-driven incentives allow physicians to clear some medical school debt while also satisfying the Legislature’s goal to have more people go into primary care and into the shortage areas, Branch says.

With providing incentives comes educating medical students about incentives for primary care. “You have to get the program out there so that medical school students, before they graduate and make a decision on what [specialty] they want to pursue, realize that the incentive is out there,” Branch says. Even if they may not receive the incentive until after their residency, “they need to know that ahead of time because you’re trying to change behavior.”

While increasing the number of medical school spots is important, so is choosing the “right” people for medical school. Valenzuela says this means getting away from past selection bias that showed preference for well-cultured students who could fit into big-society business and economies. Instead, “focus on people who are from smaller areas and people who are from underserved populations like the Hispanic population in Texas,” he says. He also encourages continued support for JAMP, or the Joint Admission Medical Program, which provides scholarships to economically disadvantaged students who pursue a medical education.

“The data says that if we recruit students from small towns and give them some of their training in small towns, it increases the likelihood of them going to small towns, though no guarantees,” Dickey says.

Other actions being taken by medical schools and residency programs to address physician distribution in Texas involve changing curricula or adding fellowships that hone future physicians’ skills for rural medicine. Six of Texas’ eight medical schools have incorporated rural track programs to entice students with a high likelihood of entering rural medicine to choose residencies and later practice in rural areas or small towns. According to a study published in Academic Medicine, if each U.S. medical school added a rural training track, the number of graduates going into rural practice would more than double.

Residency programs have also set up rural training tracks that give residents more focused training in skills they may not need in the city, like delivering babies or endoscopies, Valenzuela says. Some programs offer fellowships in procedures, geriatrics and rural training, “so that’s been the big trend for trying to increase the number of residents going into rural medicine.”

With a goal of increasing students’ interest in choosing primary care residencies and eventually going on to practice primary care, the Texas Statewide Family Medicine Preceptorship Program places students in family physicians’ offices for a month-long rotation to enhance their classroom instruction and build their skills in history-taking and physical examination, among others. Because of the way medical schools are organized, students don’t get a lot of exposure to family medicine, especially early in their careers when they’re starting to form opinions on different specialties, Foxhall says. This program counters that.

“It gives them an opportunity early on in their careers to experience family medicine and how it’s practiced in the community, and to be able to form their opinions based on very high-level role models. That experience has been found to be a positive factor in whether they decide to go into family medicine a few years later.”

Once physicians go to rural areas, Valenzuela says there could be better incentives to keep them in the communities, by supporting them and their families with locum tenens coverage, providing low-interest loans for clinic start-up and providing practice management assistance. “The other thing is keeping them financially viable,” he says, by supporting rural bonuses for Medicare, Medicaid and other insurers. As he points out, 24 percent of rural patients are uninsured, 32 percent are Medicare or Medicaid, and 44 percent have private insurance.

“Unless the state doesn’t care about care in rural areas at all, they need to understand that the only model of care to satisfy what patients need out there is the family medicine model, so there needs to be increased funding of rural physicians,” Goertz says. He understands that this might mean adjusting the reimbursements to other physicians. “The costs have changed and you cannot sustain what we’re doing without some redistribution to swing the pendulum back the other way.”

As health costs continue their steep ascent, putting the idea of affordable, accessible health care out of reach for an ever-growing number of Americans, many organizations have placed their hopes in the medical home concept. But for that model to work, there must be a sufficient primary care physician workforce trained and willing to make it a reality. “We really need to be looking at how we can increase the number of students who enter primary care training and eventually go into practice in primary care,” says Foxhall, who like many other leaders in the state’s medical field believes the number of primary care physicians practicing today is inadequate to provide medical homes to all people. “Our challenge is to see how to bridge that gap; how do we get people trained and get them ready to go?”

While many of the reforms necessary to fix a physician shortage are beyond the scope of any state government, lawmakers in the next Texas Legislature will have an opportunity to enact reforms that can strengthen the state’s primary care workforce. The only question that remains is: Will they?