Texas has one of the fastest growing and aging populations in the nation. Yet, according to recent data, Texas ranks 41st in the nation for physician-to-population ratio. For primary care, Texas ranks even lower – coming in at number 47.
In 2018, the A&M Rural and Community Health Institute and the Episcopal Health Foundation issued a report that showed some alarming results: 35 Texas counties have no physician, 80 counties have five or fewer physicians, 58 counties are without a general surgeon, 147 counties have no obstetrician/gynecologist and 185 Texas counties have no psychiatrist.
28.7 million people call Texas home and it has become increasingly clear that in order to provide high quality health care for a population as diverse and geographically widespread as Texas, the future will require significant investment in physician recruitment, training and education.
Graduate Medical Education:
Teaching (and Keeping) the Next Generation of Care Providers
Graduate medical education is a component of physician education and training that begins with an undergraduate degree and ends with a residency or fellowship. GME includes both residencies to acquire an initial specialty, such as family medicine, and fellowships to acquire a subspecialty, such as pediatric neurosurgery. Residencies take place in hospital settings and usually last from 3 to 8 years.
Because of the clear societal benefits, both the federal and state government provide public funds to Texas hospitals and medical schools to defray some of the costs of physician education and training. However, on average, the costs of training a future physician is $150,000 per resident per year – costs that exceed available government funding and which require medical institutions and hospitals themselves to increasingly invest their own funds at a time when reimbursement rates and margins are rapidly shrinking.
In 2011, the Texas Legislature established a goal of 1.1 to 1 for the number of available residency training slots to graduating medical students. That would enable all Texas medical student graduates to continue their medical training in Texas – a factor known to increase the likelihood that a physician will remain in the state to practice medicine upon completing training.
In 2017, after considerable investment and planning by the state legislature, Texas achieved that goal. However, sustaining this goal promises to remain challenging – particularly as the number of Texas medical schools and graduates increases at a rate faster than the number of available GME slots.
Robert Hendler, M.D., chief medical officer at the Texas Hospital Association expressed concerns that, in order to meet the GME needs of hospitals and Texas while maintaining a desired 1.1 to 1 ratio of training slots to medical school graduates, many Texas hospitals are being forced to carry the weight of not just recruiting physicians but also providing the necessary staff and resources to educate future physicians as well. In some cases, hospitals have exceeded the available federal funds twice over and have utilized available state funds and their own capital to supplement GME programs.
“We’re all aware that we have gaps to fill and we know that if we can continue to create more GME spots, we have a better chance of keeping our doctors in the state after graduation,” said Hendler. “That’s a commitment Texas should continue to make.”
‘Getting Them on the Plane’
Jessica Loy, a physician recruiter at The Hospitals of Providence in El Paso discussed recruitment challenges and said, “The hardest thing is just getting the physician on the plane – once they’re here, they fall in love with the city.”
In Texas, most hospitals cannot directly employ physicians, but Loy says that in some instances, the hospitals are able to assist new physicians who want to join a local practice through a salary guarantee, incremental expenses and relocation assistance. Moreover, the hospitals are doing their part by fostering collaboration between the incoming physicians and the resources they need access to.
In El Paso, Loy identified the biggest physician deficient as being primary care – echoing the sentiments of physician recruiters and hospitals around the state. “Our last community-needs assessment identified a deficit in primary care physicians of more than 350. That’s a hard deficit to overcome,” said Loy.
To overcome that deficit, the Hospitals of Providence, a subsidiary of Tenet Healthcare, recently opened a new facility, The Hospitals of Providence Transmountain Campus in conjunction with Texas Tech to start new residency programs. “We’re hoping that some of the residents who receive their training through our new residency programs will also fall in love with the city and stay here,” said Loy. The first residency programs with Texas Tech based at The Hospitals of Providence Transmountain Campus will start in 2021 and will be primary care based.
Russell Meyers, president and CEO of Midland Memorial Hospital, understands the importance, and difficulty, of physician recruitment in communities that don’t have the resources or lifestyle that could be offered in a larger city. Meyers identified the key to Midland’s success as their community partnerships – highlighting the Midland Development Corporation, a board appointed by the Midland City Council to promote business expansion, job creation and capital investments, that has worked with area hospitals to help meet infrastructure and staffing needs.
By covering a significant portion of the upfront costs of recruiting and bringing doctors to the community, Meyers says MDC has “recognized that our community's ability to grow and to make this a livable environment depends on more than just bringing the business here. You must have the infrastructure in place. You’ve got to have physicians and other health care professionals. You need good schools and affordable places to live – all of those things are necessary for the economic miracle to continue.”
Another example is Hendrick Health System in Abilene. Joe Pearson, senior vice president of operations and development, points to their Medical Staff Development Committee as being a key tool to their success on the physician recruitment front. “There are always things we can do better and there’s a never-ending need for good physicians. But we place a lot of emphasis on physician recruiting. Our Medical Staff Development Committee includes four physicians, four community leaders, and four of our hospital board members. This diverse makeup allows them to properly gauge and predict the staffing needs of the community and this committee has been an important component of our success,” said Pearson.
Rachel Lee, a physician recruiter at Hendrick Health System emphasized that another contributor to their physician recruitment success has been the hospital’s commitment to “courting” residents even when they’re still years away from graduation. “We spend a lot of time on the road going to different training programs, getting to know the fellows and residents and their families and letting them get to know us,” said Lee. “While remaining within fair market value, we’ve increased our benefits and compensation package to be more competitive. We also provide visa sponsorships,” she said. The emphasis on starting early and building relationships seems to be paying off – Hendrick already has seven physicians signed to start in 2020, six to start in 2021, and one for 2022.
Collaborative Care and Rural Health
Hendrick Health System is located in Abilene but serves 24 surrounding counties as well – many of them small, rural, ranching communities. Pearson emphasized the importance of building collaborative care networks. “We work really hard to build good relationships with those communities and rural hospitals. Most of them have their own primary care physicians and we don’t want to compete against them - we want to work with them,” said Pearson.
In many cases, simply working together has provided access to care that would not be able to exist otherwise. For example, Hendrick employs 10 cardiologists, but their rotations cover 14 external specialty clinics in surrounding rural communities. Pearson put it this way, “One of our cardiologists could go to Sweetwater and work out of the hospital there – providing greater convenience and accessibility for the patient. That is what’s really important.”
When asked about what the future holds for Texas’ physician-to-population ratio, Jennifer Banda, vice president of advocacy and public policy at the Texas Hospital Association, stressed the need for increased federal funding for physician training. “Federal GME funding comes primarily from the Medicare program but Medicare funding in each state is limited to a capped number of residents. The caps were set in 1997 and don’t account for the massive population growth and shifts that have occurred since then – putting Texas hospitals at a major funding disadvantage compared with other states,” said Banda.
While physician recruitment will continue to be difficult in more rural areas, Susan Wade, vice president of infrastructure and support at Hendrick Health System has high hopes for the future. “It all boils down to the culture – we care for the community and our employees as if they are family. And we’ve invested in the facility and the technology, so physicians know that if they come here, they’ll be supported and have what they need,” Wade said. “That’s how we’ll get physicians in the door.”
“Over the past few years, The Texas Legislature has appropriated more funds for physician education and training independent of the Medicaid program – so that’s been really encouraging to see and we’ve made great strides,” said Banda. But she stressed that there is still more work to be done. “Our goal is to make sure that every Texan has access to affordable, high quality health care. That means working towards solutions to ensure our hospitals have the funding they need, that our physicians are receiving the education and support that they need, and that we’re all doing our part to fill those gaps in care.”