Review of 1995 and 1996 TMA Policies on Physician Workforce

The following policies were reviewed by the Council on Medical Education at meetings held in September 2005 and February 2006 as part of the House of Delegates 10-year review and update. Input from the Committee on Physician Distribution and Health Care Access was considered in the policy review. The council's analysis and recommendations for retention, deletion, or amendments to the individual policy statements are summarized in this report. 

The following policy items are detailed descriptions of initiatives to increase the number of primary care physicians. In lieu of Policy 185.012 and the primary care references in Policy 200.026 below, the council recommends amendments to Policy 185.002 Physician Workforce Primary Care Training, as shown.

185.012 Primary Care : TMA supports the statutory goal to increase the number of resident physicians and fellows in Texas graduate medical education programs in family medicine, general internal medicine, general pediatrics, geriatrics, obstetrics/gynecology, and emergency medicine.

TMA supports the efforts of Texas medical schools and teaching hospitals, and other state incentive programs, to encourage graduating medical students to enroll in family medicine, general internal medicine, general pediatrics, geriatrics, obstetrics/gynecology, and emergency medicine and to practice in these medical specialties and in medically underserved areas of the state.

TMA encourages Texas medical schools to continue to increase their efforts in exposing medical students to curricula and extracurricular programs and activities that tend to encourage students to enter medical specialties of family practice, general internal medicine, and general pediatrics, and in making administrative changes that are cited in the literature as having a positive impact on student selection of family practice, general internal medicine, and general pediatrics.

TMA encourages Texas medical schools to continue to increase their efforts in selecting qualified students (especially those from underrepresented minority groups) who will select medical specialties in family practice, general internal medicine, and general pediatrics.

TMA supports Texas medical school efforts to increase programs and activities that provide early exposure to clinical training in family practice.

 TMA supports Texas medical school efforts to increase programs and activities that provide early exposure to clinical training in general internal medicine.

TMA supports Texas medical school efforts to increase programs and activities that provide early exposure to clinical training in general pediatrics (Committee on Physician Distribution and Health Care Access, p 76, I-95).

200.026 Residency Training Programs : The Texas Medical Association supports the efforts of Texas residency and fellowship training programs to recruit, enroll, and retain qualified underrepresented minorities, which is likely to increase the racial /ethnic representation of physicians practicing in Texas.

TMA encourages Texas residency training programs to provide opportunities for residents to train in small cities or rural communities during part of their graduate medical education. These opportunities include rural rotations for existing residency training programs, expansion of existing urban-based programs into small city or rural locations, and establishment of new programs in small city or rural locations.

TMA encourages Texas residency training programs to continue to strengthen and enhance graduate medical education programs in family practice, internal medicine and pediatrics so that Texas residency training programs in these medical specialties can successfully compete and attract increasing proportions of qualified U.S. medical graduates to their programs.

TMA believes that the State of Texas should (1) expand funding to continue to strengthen and enhance graduate medical education programs in family practice, internal medicine, and pediatrics; (2) establish incentive programs to attract U.S. medical graduates to train in Texas residency programs in family medicine, internal medicine and pediatrics; and (3) enhance existing loan reimbursement programs to continue to strengthen and enhance graduate medical education programs in family practice, internal medicine, and pediatrics so that Texas residency training programs in these medical specialties can successfully compete and attract increasing proportions of qualified U.S. medical graduates to their programs (Committee on Physician Distribution and Health Care Access, p 77A, I-95).

185.002 Physician Workforce Primary Care and Specialty Training : The Texas Medical Association:

(1) Recognizes primary care specialties as family practice, general internal medicine, general pediatrics, and obstetrics/gynecology.
(2) Supports the concept of primary care training in Texas medical schools.
(3) Supports the concept of individual freedom of choice of Texas graduates in choosing careers.
(4) Supports approval of appropriations and adequate funding of the family practice clerkship.
(5) Supports continuing efforts to prepare primary care physicians to meet the state's needs, particularly in rural, border, and inner-city shortage areas. TMA also recognizes the growing specialty shortage and strongly supports efforts to increase access to specialty care in Texas through adequate training opportunities in shortage specialties. To recruit and retain physicians to provide for the state's health care needs and ensure access to care, TMA supports state efforts at tort reform, restoring affordable professional liability premiums, and obtaining higher Medicaid, CHIP, and Medicare provider fees.
(6) Encourages Texas residency training programs to provide opportunities for residents to train in small cities or rural communities during part of their graduate medical education. These opportunities include rural rotations for existing residency training programs, expansion of existing urban-based programs into small city or rural locations, and establishment of new programs in small city or rural locations.
(7) In defining the state's physician workforce needs, the Texas Medical Association recognizes that primary care physicians are an important and vital component of the healthcare delivery system for meeting the state's medical needs.  Accordingly, the Texas Medical Association supports medical school efforts to recruit students with an interest in these specialties and to foster that interest on into residency.  Further, the Texas Medical Association supports public funding of incentive programs with demonstrated effectiveness in recruiting and retaining physicians in areas with geographic and/or specialty maldistributions (Council on Medical Education, p 95, I-92; amended CME Rep. 6-A-03).

Background:  Ten years ago, the shortage of primary care physicians was one of the most critical concerns in relation to the physician workforce. At the height of the managed-care era and prominent use of the gatekeeper model, there was a steep rise in demand for primary care physicians and family physicians in particular. Communication efforts were largely effective in raising consciousness and altering public opinion on this issue. The Texas Legislature responded by establishing a multitude of programs designed to increase interest in primary care careers and recruit and retain more physicians in these specialties. State and federal efforts included:

• A new state law mandating a third-year family practice clerkship for all Texas medical students;
• New state appropriations allocated to primary care residency programs;
• Creation of preceptorship programs in general internal medicine and general pediatrics in addition to the existing family medicine program; and
• Federal and state loan repayment programs established for primary care physicians.

These programs achieved results and a majority remains intact. Texas experienced a steady, healthy gain in the primary care physician workforce as shown in the table below. The supply of primary care physicians grew 46 percent from 1995 to 2005, or by about 500 per year.  Perhaps, more importantly, the number of primary care physicians grew 2.5 times faster than the state's population which expanded by 18 percent during the decade.  With the workforce gains outpacing population growth, many Texans likely have experienced improved access to medical care. 

Change in Primary Care Physician Supply and Ratios to Population for Texas, 1995 and 2005

The council is not advocating for a decreased emphasis of the need for primary care physicians in the state. Rather, the council recommends amendment of current policy that recognizes the continuing need for more primary care physicians and growing need in some medical specialty areas as replacement for the detailed, lengthy list of program-specific policy statements contained in Policies 185.012 and 200.026.

Recommendation 1 : Retain as amended.

The council reviewed 205.013 and determined that it should be deleted.

205.013 Residency Programs Funding :The Texas Medical Association supports implementation of a mechanism of funding for graduate medical education in which residency training positions are provided to (1) 100 percent of qualified U.S. LCME and AOA graduates by way of federal direct and indirect graduate medical education budgets; (2) a balanced number of international medical graduates (IMGs) supported by foreign governments based on the sponsoring nations' ability to fund those residents; (3) an additional number of residency positions for IMGs not to exceed 10 percent of the number of U.S. LCME graduates by way of federal direct and indirect graduate medical education budgets (Medical Student Section, p 181, I-96).

Background:  It is not known whether 110 percent remains an appropriate goal for Medicare funding of entry-level graduate medical education (GME) slots in order to meet our state's growing physician demand. In lieu of specific policy, the council recommends monitoring the number of Medicare-supported entry-level GME slots in the state. 

Recommendation 2 :  Delete.

The council reviewed the following policy and determined that all sections with the exception of Item 2 should be deleted. Item 2 is not duplicated in other TMA policy and should be retained.

255.003  Primary Care Initiative Undergraduate Medical Education : The Texas Medical Association adopted 1997 primary care initiatives which include goals for:

(1) Graduate Medical Education (a) enhancing funding of existing family practice residency training program, (b) incorporating funding of the family practice pilot program into the family practice residency training program, (c) continuing to increase the number of state-supported primary care residency positions by 150 positions per postgraduate year, (d) maintaining funding for the resident physician compensation program;

(2) Undergraduate Medical Education Texas Medical Association initiatives for graduate medical education include (a) maintaining expanding the preceptorship programs in family medicine, general internal medicine , and general pediatrics for undergraduate medical students, and (b) funding faculty enhancement program for generalist physicians ; and

(3) Physician Recruitment and Retention/Access and Health Care Delivery (a) funding the underserved community-state matching incentive programs for primary care physicians (Council on Medical Education, p 71, I-96).

Background : Item (1)(b) references the family practice pilot program which no longer exists; the program was de-funded by the Texas Legislature in 2003. Similarly, item (1)(c) expresses support for the addition of 150 new state-funded primary care residency positions per year. This was part of a state initiative led by The University of Texas to increase the availability of primary care residency positions in response to the primary care crisis of the mid-1990s. Although TMA continues to support increased levels of state GME funding, this particular state initiative is no longer active. It has effectively been replaced by the state formula funding process established by the legislature for 2006-2007. The program identified in item (1)(d), the resident physician compensation program, also was de-funded by the legislature in 2003. Item 2 is not duplicated elsewhere in TMA policy and should be retained.

Recommendation 3 :  Retain as amended.

In lieu of the original language of 185.012 below, the council recommends adoption of new language shown below:

185.012 Physician Distribution and Health Care Access : The Texas Medical Association reaffirmed its support of Texas medical school efforts to recruit, enroll, and retain qualified underrepresented minorities. (Every effort should be made to provide adequate financial support to these students so that a medical education is within the reach of all qualified Hispanic, African-American and other underrepresented minority students who desire to become physicians, and Texas medical schools can successfully compete with non-Texas medical schools in attracting these students.)

Background : The council recognizes the ongoing need to recruit more students from underrepresented minorities and is aware of access to care problems due to geographic disparities in physician supply.  Accordingly, the council recommends a combined policy that acknowledges both race/ethnic and geographic disparities in access to care, as shown below:

185.012 Physician Recruitment :  Texas is experiencing a rapid and sustained growth of minority populations, among Hispanics in particular, as evidenced by the 2005 shift in the state's population demographics. Currently, no single race/ethnic group holds a majority in the state but the combined total of Hispanic, African-American, and other non-Anglo race/ethnic groups now exceeds 50 percent.  Research studies have established that patients prefer to receive their health care from physicians who look like them yet the percentages of Hispanic and African-American physicians among the Texas workforce fall far short of the state's changing demographic profile. The growing body of research on health disparities among some minority populations also lends added urgency to the need for improving access to care through greater diversity among the physician workforce. It is further recognized that the 2003 U.S. Supreme Court ruling on higher education admissions criteria may facilitate greater recruitment of minorities into Texas medical schools.

Accordingly, the Texas Medical Association supports expanded efforts by Texas medical schools to recruit and retain students and residents from underrepresented race/ethnic groups as well as underrepresented geographic areas of the state to enhance the diversity of the state's physician workforce, affect geographic maldistribution, and reduce potential health disparities.

Recommendation 4 :  Approve substitute policy.

TMA House of Delegates: TexMed 2006