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Building the health care infrastructure

Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association

March 2016

Texans take pride in the fact that our state is one of the fastest-growing in the nation. People move here for the jobs, the economic growth, and the way of life. The state demographer estimates that by 2050, the population will top 54 million – double what it is today.

With this growth, however, come challenges. Traffic and building a transportation infrastructure to accommodate this many Texans almost immediately come to mind as logistical and fiscal challenges. But just as challenging is having a health care infrastructure that can deliver timely and quality health care to this many people. Fundamental to this infrastructure is workforce – the physicians, nurses, and allied health professionals who deliver care. Unfortunately, the state is starting from a disadvantaged position. We already have a lower-than-average physician to population ratio. Among the most severe shortages are those for primary care physicians, endocrinologists, psychiatrists, geriatricians, and pediatric subspecialists. Add to this explosive population growth, and we have a significant access to care problem.

In our complex and changing health care environment, any discussion of workforce adequacy also needs to include nurses and allied health professionals, all of whom are essential members of the healthcare team. But right now in Texas, there is a documented shortage of nurses and a number of types of allied health professionals. The Texas Center for Nursing Workforce Studies estimates that between 2005 and 2020, the demand for registered nurses in Texas will rise by 86 percent. However, supply will grow by only 53 percent, leaving Texas 71,000 full-time equivalents short of its needs. There are also shortages of pharmacists; radiological technologists; medical lab technologists; surgical scrub techs; hospital-based physical therapists, audiologists and speech-language pathologists; and ultrasound techs.

Hospitals, academic medical centers, and other health-related institutions are major financial supporters of GME in Texas that carries an estimated conservative price tag of $150,000 per year per resident. Texas is one of a handful of states that does not pay for GME through the Medicaid program. It funds a fraction of GME expenses through a formula allocation of $4,400 per resident. Medicare is also a supporter, but its contribution is capped at the level provided in 1996. This means that of the state’s approximately 6,100 residency slots, more than 2,000 are ineligible for any Medicare GME funding and require full funding from the residency programs and hospitals themselves. In addition, even for Medicare GME-funded slots, residency programs pay about two-thirds of the training costs.

In the absence of additional state funding, training more physicians, so desperately required to meet the health care needs of a growing population, would require additional investment from hospitals and health systems at a time when they are already dealing with significant reimbursement rate cuts and a large number of uninsured patients.

Fortunately, the state legislature has responded. In each of the last two legislative sessions, lawmakers have appropriated funds to increase the number of graduate medical education opportunities for physicians in training. These positions are essential because physicians who train here are more likely to stay here and build practices. Conversely, those who leave the state for training are less likely to return to Texas to practice.

Last month, the Texas Higher Education Coordinating Board announced the award recipients of $49.2 million in grants to support the expansion of graduate medical education opportunities in Texas. These grant funds are being disbursed to 23 Texas medical schools, hospitals, and health systems to support 65 training programs and 224 residency positions in 2016 and 459 positions in 2017. The funded positions are in internal medicine, pediatrics, family medicine, emergency medicine, obstetrics and gynecology, psychiatry, neurology, and surgery.

These funds are absolutely essential to address the state’s serious physician shortage and the access difficulties it creates for residents across the state.

In addition, since 1999, Texas has used funds from the Texas Tobacco Lawsuit Settlement to address the state’s nursing shortage. These grants have been essential for promoting innovation in the education of initial RN licensure nursing students. The 84th Legislature extended this funding through 2019 to make nursing students and faculty education, recruitment, and retention an explicit state priority.

Texas lawmakers have made a significant investment to foster a healthy health care provider workforce and sustain the backbone of the state’s health care infrastructure. Sustaining and building this investment will be essential in future years.