President's Page

President's Page
July 2007

Train them at home, and they'll stay at home:

Graduate Medical Education, part 2

by James T. Norwood, MD
2007 DCMS President

Last month I discussed the results of the resident match for 2007. I highlighted some numbers from the National Resident Matching Program and some changes taking place. This month I will highlight graduate medical education (GME) in Texas.

The population of Texas is increasing, as is the number of physicians coming to Texas. The rate of population growth, however, is exceeding the rate of physician growth. One tangible benefit from the passage of Proposition 12 is the improved practice climate in Texas. This has created a surge of applications to the Texas Medical Board from physicians who now want to practice in Texas. But this increase still doesn’t close the gap between physician supply and the number needed for our state’s patients.

Another source of practicing physicians is our residency training programs. Studies have shown that where physicians do their postgraduate education significantly influences where they stay to practice. Texas medical schools are graduating a record number of physicians, but our state has not kept up with a concomitant increase in GME positions. Many of those graduates must leave the state for their residency programs. This significantly increases the chance that they never will return to Texas to practice. With the state spending an average of $200,000 for each medical student’s education, this loss of physicians also means a loss of the taxpayers’ investment in their education.

According to the US Census Bureau, the 2006 estimated population of Texas was 23,507,783, a 12.7% increase from 2000. For New York the 2006 population estimate is 19,306,183, which is 1.7% higher than in 2000. That same year there were 36,450 direct patient care physicians in Texas and 51,581 such physicians practicing in New York. That is a large discrepancy, especially considering how much faster the Texas population is growing.

Why is there such a difference? New York is not exactly a haven for physicians. It’s in the middle of the same liability crisis that Texas experienced until voters passed Proposition 12. One reason New York has more physicians is because it trains more physicians. According to the TMA, last year Texas had only 6386 GME slots, compared to New York’s 15,084. Additionally, Texas state funding for GME is 60% less than it was 5 years ago.

A 1995 report by the Council on Graduate Medical Education published an analysis by the National Conference of State Legislatures that revealed that the location of the medical school a student attends has a direct influence on where the graduate will do his residency. The location of the most recent graduate medical training has a direct relationship on the choice of practice location. In short, if we want more physicians in Texas, then we need to train more physicians in Texas. But training physicians is not free. Then again, not training more physicians in Texas may be even more expensive.

You may think this impacts only the number of resident physicians trained in Texas and ultimately the number of physicians practicing in Texas. You may not see a need to increase the number of physicians in Texas. Who needs an abundance of physicians to compete with? Maybe if we keep the physician supply a little tight, the existing physicians can get better reimbursement as the demand for health care goes up. This is a nice idea, but it’s not reality.

Texas already has a physician shortage, but that didn’t keep the Legislature from cutting Medicaid reimbursement during its 2005 session. Participation in Medicaid dropped, but these patients still had to get medical care in Texas. Their care still was paid for by the state or a federal matching program, and lot of the care was not reimbursed. Their health care now was more expensive because the ER was their doctor’s office. This more expensive health care used tax money that came out of your pocket. Thankfully, the Legislature increased reimbursement during its last session, but not enough to counteract the effect of inflation on your expenses.

The private market also is a mutated one. The relationship between the employer and the insurance company is what drives revenues. The shortage of physicians in Texas has not resulted in improved reimbursement or access with private insurance companies, as evidenced by the large number of patients who are employed full-time but have no health insurance or inadequate health insurance. This large pool of patients still gets health care in Texas, provided by tax dollars. The state’s hand is now getting deeper into your pocket.

The graduation program from UT Southwestern Medical School shows that it conferred 223 diplomas in June. Just 100 of those graduates are staying in Texas for their post-graduate training. If only half of the 123 graduates who are doing their residencies outside Texas don’t return to Texas to practice, that results in a $12.3 million state investment leaving Texas to benefit another state. That means more tax money out of your pocket.

Training more resident physicians in Texas is not only good for the health of the population, but also for the economy, especially considering that resident physicians under supervision of their faculty take care of the vast majority of uninsured and under-insured patients in our state. Increased funding for GME increases the number of physicians training in Texas, increases physicians in our supply pipeline who likely will stay in Texas, and immediately provides health care for those who have the hardest time accessing it. These reasons don’t even include the subtle changes seen with graduate medical education programs, such as the enhanced intellectual environment in those communities and improved health quality.

So, what can you do about this? The Legislature has adjourned, but this is a great time to educate yourself and prepare for the next session in January 2009. A good source of information is the previously cited resource paper from the Council on Graduate Medical Education titled “State and Managed Care Support for Graduate Medical Education: Innovations and Implications for Federal Policy.” This was published in July 2004 by the Department of Health and Human Services and is available online at http://www.cogme.gov/rpt6.htm. The analysis looks at states that have tried new ideas for GME funding, such as a system where a combination of federal, state, and private funds is directed to graduate medical education. It is a complex issue that we physicians need to understand and then educate our policy makers about. Our patients and our practices are depending on us.

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