As New Medical Schools Come Online, A Concern Rises About Availability Of Texas Residency Slots

By the fall of 2018, three new medical degree programs will be online in Central, North, and South Texas.

The rush kicked off in 2009 with Texas Tech’s Paul L. Foster School of Medicine in El Paso, which became the eighth MD program in Texas and the first in nearly four decades. In 2016, the University of Texas System will welcome the first classes of both the Dell Medical School in Austin and the School of Medicine in the Rio Grande Valley. A joint collaboration in Fort Worth between the UNT Health Science Center and Texas Christian University will follow in 2018. These schools will add more than 300 new students by 2022, with more to follow as the programs expand.

It’s no secret Texas is facing a physician shortage, particularly in rural communities and the economically disadvantaged pockets of its urban cities. According to a recent study led by Irving-based physician recruitment firm Merritt-Hawkins, Texas needs to add another 12,819 physicians for it to meet the national average of 226 per 100,000 residents. The recent wave of new MD programs is meant to help address this.

“Texas is ranked 45th in the nation for physicians per capita,” said Dr. Michael Williams, president of the UNT Health Science Center. “This is a rounded number, but the TMA (Texas Medical Association) published data showing we’re going to be around 6,500 primary care physicians short by 2030. That’s only 15 years away.”

But a challenge remains: MD students need residencies. And there’s a concern that Texas isn’t adding enough to keep up with demand. According to TMA figures, there were just 24 more residency positions than graduates in 2013. To achieve the coveted 1.1:1 ratio of residency positions to graduates (as recommended by the Liaison Committee on Medical Education, the accreditation firm for MD programs), Texas would need to add an estimated 589 residency slots by 2022—and that was an estimate before UNT and TCU announced their partnership.

“I’ve got several hospital systems within a rock’s throw from each other in the Fort Worth Hospital District and there’s essentially no GME (graduate medical education) going on in those hospitals except for public teaching hospital JPS,” Williams says. “What I saw here was an untapped reservoir of future GME program development.”

Fort Worth is among the largest cities in the country without an MD track. UNTHSC does offer a Doctorate of Osteopathic Medicine (a DO), which is held by about 25 percent of practicing physicians, according to the Association of American Medical Colleges. Offering an MD track, Williams said, was a way to create a more comprehensive education program as well as address the impending physician shortage. The UNT Board of Regents charged the school with pursuing such a program in 2009, but the piece of legislation that created the Health Science Center in the nineties also barred it from issuing MD degrees. To get around that, the school partnered with TCU, which is where the majority of the money will come from as well as the name that will sit atop diplomas. Now it’s full steam ahead.

Williams’ hope of future GME program development is, however, expensive. It can cost between $120,000 and $160,000 per resident per year in a new program, and between $50,000 and $60,000 if it’s expanding a current program. A standard residency is funded through a mix of federal, state, and private dollars.

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At the federal level, a cap on Medicare support of GME has been in place for the past 18 years. Advocates such as the aforementioned Association for American Medical Colleges have banged the proverbial drum for years to no avail—congressional legislation to break that cap has never found its footing.

But there is activity at the state level. In the last session, Sen. Jane Nelson, R-Flower Mound, authored Senate Bill 18, which glided through the statehouse without a single opposing vote. The legislation funnels about $60 million to create new GME positions to help the state grow its residency slots to outpace graduates by 10 percent (that previously mentioned 1.1:1 ratio).

In 2013, a report presented by the Texas Higher Education Coordinating Board to the Legislature stressed that if new slots weren’t added, the state would be short 30 by 2015. Considering the state invests an average of $180,000 per medical graduate during their initial four years of training, losing 30 of these practitioners could cumulatively cost Texas $5.5 million—not to mention the high probability that they would stay within 50 miles of their out-of-state residency (which more than half do).

“We invested in graduate medical education this session because we need more healthcare professionals to serve our growing population, and we want to have enough residency slots to retain our Texas graduates as well as recruit from other states,” Nelson wrote in an email. “As more medical schools are built, the cost of maintaining that ratio will increase.”

As of 2013, there were a total of 1,611 residency slots and 1,587 graduates. Nelson’s bill, according to the Legislative Budget Board, will pay for an estimated 125 new GME positions. This almost certainly won’t be enough for when the new schools begin producing graduates, but many believe it’s a sign that the state will be willing to address the issue as that date nears. The first graduate class from the new schools will emerge in 2020—there are two legislative sessions between then and now.

“This is probably going to be something we have to continue to work at and work at,” says Dr. Dan Varga, chief clinical officer of Texas Health Resources. “If we can incrementally continue to support through increased funding slots, hopefully that’s going to help us increase the number of medical residents who end up remaining in Texas and practicing here.”

THR, which sees more patients in an acute setting than any other system in the region, offers 24 internal medicine residency spots at Texas Health Presbyterian Hospital Dallas. It also offers affiliate residencies through UT Southwestern, which allows residents from there to cycle through Presby and a few of its other hospitals. THR, based in Arlington, has a significant presence in Tarrant County.

It is one of Williams’ most obvious targets, even though Varga said the school and the health system had no concrete plans and had not yet discussed partnering or expanding GME together. But, he added, THR would gladly engage in conversation as long as the curriculum furthers an integrated care model that emphasizes different providers—physicians, nurse practitioners, physician assistants, as well as the use of technology such as telemedicine—in the appropriate settings, a strategy that Williams promoted when he announced the school earlier this month from downtown Fort Worth: ““One of the big keys is to develop team-based care … (by having) all kinds of healthcare experts to come around the patient to make the absolute best care plan,” he said.

“I’m not a real believer that just building more medical schools necessarily solves your workforce problem,” Varga says. “It’s not just do you have the bodies—it’s an issue of how are the bodies integrated into a care delivery model? How are they integrated into an access model? Just throwing bodies into the marketplace and hoping they solve the access problem probably isn’t the most efficient way to approach it.”

Essentially, there’s a long path ahead and plenty of decisions to be made before the healthcare industry can predict whether there will be a shortage of residencies once these new graduates emerge from their medical schools. There are bright spots. The state legislature has shown interest in helping allay the problem, considering SB 18 and legislation in the session prior that helped pay for rural hospitals to research the possibility of creating GME programs. Locally, in addition to JPS, HCA North Texas-owned Plaza Medical Center also offers residencies in Fort Worth. That hospital has six GME programs that offer 70 residencies, said CEO Clay Franklin. Too, Plaza can “expand current programs or add new training programs as the community need arises.”

“I would say that at this point, that issue has not been solved. Conceptually we understand what we have to do but in terms of actual implementation, that to me remains to be seen,” said Phil Miller, a senior vice president at Merritt-Hawkins who has studied this concern. “It’s quite a challenge to get that infrastructure in place to create these residency programs. They can’t be done overnight and whether they can keep pace with the number of medical school graduates to me is very much an open question. But I think it’s great we’re making the effort and making progress.”

Correction: An earlier version of this story said Fort Worth is the largest city without an MD track. That was not correct. San Jose, which has about 200,000 more residents, does not have one either.