By Tom Banning
There is not a self-respecting health policy analyst here or anywhere in the country who will say otherwise – we need to invest in and produce more primary care physicians.
The conventional economic wisdom, backed by common sense and an abundance of evidence drawn from the real world, is that patients with ready access to primary care receive more timely and optimal health care services with better outcomes. Primary care physicians provide preventive, coordinated, and continuous care which results in less invasive and costly medical intervention and reduces the probability of redundant or unnecessary services.
More than 20 years ago the Council on Graduate Medical Education issued a clarion call to policymakers warning that our nation had too few primary care physicians and too many specialty physicians. Yet, despite the overwhelming number of studies that have conclusively documented the critical need to strengthen our primary care infrastructure, political and budgetary decisions have stalled efforts to address this problem.
Multiple factors contribute to Texas’ inability to produce an adequate supply of primary care physicians to care for our growing population. Over the years, a significant payment gap has developed between primary care and specialty physicians. Add to that the rising cost of medical education, which saddles medical school graduates with an average of $157,000 in debt, and it’s not hard to see why medical students gravitate toward careers in procedural specialties that are better compensated.
But there are other influences at play. In 1997 the Centers for Medicare and Medicaid Services capped the number of graduate medical education positions it funds through Medicare. Since then, growth in new residency positions has been funded largely by academic health centers and teaching hospitals. They have responded rationally to current economic incentives by transferring support away from primary care training in favor of developing more procedure-intensive specialists. These residents in training essentially serve as cheap labor, producing significant revenue for their respective institutions to make up for the loss of federal and state educational support.
These factors have led to a severe shortage of primary care physicians in Texas, as more than half the state’s counties are designated primary care health professional shortage areas. With fewer primary care physicians to care for Texas families, more and more patients will be forced to seek basic health care services in already overcrowded emergency rooms at a much higher cost to everyone.
Making matters even more dire, Texas will soon be graduating more medical students than we have first-year residency training slots. Texas taxpayers will spend $160,000 to educate each medical student only to force some of these newly minted physicians out of state to complete their residency training. Research shows that the location of residency training is highly predictive of where physicians ultimately decide to practice. In real terms, Texas will be subsidizing other states’ physician workforce.
Our elected leaders’ inability, some might argue unwillingness, to adequately invest in the development of our primary care workforce guarantees this problem will only get worse, not better, which will have a profound impact on the health and well-being of Texans and our state’s economy. Our lack of investment in developing this critical workforce will guarantee inevitable and preventable medical costs are shifted downstream at a much higher expense to local hospitals, taxpayers, and those with private insurance.
In 1910, Abraham Flexner released a groundbreaking report that fundamentally reformed our medical education system. He was led by a vision that “scientific inquiry and discovery, not past traditions and practice, should point the way to the future in both medicine and medical education.”
It has been over a hundred years since the Flexner report transformed medical education and training. Perhaps it is time to hold our academic health centers and teaching hospitals accountable for the physicians they produce and incentivize them to produce the right kind of physician workforce Texas needs.
It is said that every system is perfectly designed to get the results it gets. Our current medical education system is designed to under-produce the primary care physicians Texas desperately needs. Our system must change because if we always do what we’ve always done, then we’ll always get what we’ve always gotten. In the case of Texas’ physician workforce, the viability of our health care delivery system and security of our economy, the status quo is simply not sustainable.