Proposal Pits Primary Care Against Specialties

A controversial budget proposal would concentrate the money the state spends on graduate medical residencies into the doctors’ first three years of training — regardless of how long their residencies take to complete.

That means it would fully fund family physicians and internists, whose training takes three years — but not specialists like cardiologists and radiologists, who take four to seven years to train.   

Proponents say the budget rider would give residency programs an incentive to produce the primary care doctors Texas desperately needs, because those slots would be fully funded. They say residents who go into specialties that take longer than three years are often paying for themselves — because they’re providing services their supervisors can bill for.   

“It is the state’s obligation to use tax dollars in a fashion that best serves the citizens of Texas,” said Dr. Nancy Dickey, president of the Texas A&M Health Science Center, which has one of the state’s largest family medicine residency programs. “As we try to address a physician shortage in a state that continues to grow its population, it would be appropriate for legislators to consider selective use of graduate medical education funds.”

But opponents say it’s misleading to suggest residents in any specialty are making money for their hospitals, especially since they’re now barred from working more than 80 hours a week. They say cutting off funding for years four through seven would have a devastating effect on surgical specialties and those that lose the most residents to other states, from neurology to urology.

“Texas needs specialists and primary care physicians,” said Dr. Susan Bailey, president of the Texas Medical Association. “I would hate to see us sacrifice one for the other.”

Lawmakers on the House Appropriations Committee are slated to discuss this and other budget proposals on Thursday. In the last budget cycle, they appropriated nearly $80 million to fund Texas residency programs at 10 state medical institutions, which were training a combined 6,000 doctors across all specialties. Facing a looming budget shortfall this time around, they intend to spend just $57 million in the upcoming biennium — more than 30 percent of it to train residents in years four through seven.

Texas has a physician shortage across all medical fields: In 37 out of 40 major specialties, it ranks below the national average of physicians per 100,000 people. It’s particularly pronounced in primary care, where last year, just 8 percent of Texas medical students went into family practice, down from 14 percent in 2001. More than a quarter of those students left Texas for out-of-state residencies, a strong indicator that they won’t practice in Texas.

Family practice advocates say that if the state's graduate medical education money was all funneled into the first three years of training, the state could increase per-resident funding substantially, and spend the remainder on programs to attract more primary care doctors to the state — many of which have been slashed or zeroed out in this tough budget cycle. They say it makes little sense for Texas to subsidize residency training in years four through seven, because those residents are often generating enough revenue, via their attending physicians, to cover the cost of their training.

“That money could be plugged into the front end, where the true costs are, or used to create more residency slots,” said Tom Banning, CEO of the Texas Academy of Family Physicians.

Bailey, with the TMA, said residents may be covering their own costs “in a very few surgical specialties.” “But a psychiatrist in his fourth year is not going to pay for himself,” she said. “A neurologist in his fourth year is not going to pay for himself.”

She said hospitals certainly aren’t making big bucks off of residents, especially because there are now strict limits on how many hours residents can work. “If anything, it’s become more expensive to train residents because hospitals are now having to hire folks to fill in the gaps where the residents can’t be on duty anymore,” she said.

Other opponents of the rider say Texas’ future need for specialists will outpace the need for primary care doctors. Dr. Linda Andrews, senior associate dean of graduate medical education at the Baylor College of Medicine, said the rider would hit four-year specialties, like obstetrics, gynecology and psychiatry, particularly hard. And it would have a disproportionate effect on med schools like Baylor, the University of Texas Health Science Center at Houston and UT-Southwestern in Dallas, which have more residents in years four through seven because of the specialty services required at the major urban hospitals they serve, like Houston’s Ben Taub and Dallas’ Parkland.

“If you stop funding those graduate medical education slots,” she said, “you would harm the ability of those schools and hospitals to provide needed care to their patients.”

Banning thinks that’s an unfounded fear. He said recent studies suggest medical schools and residency programs have been developing a workforce that increases revenue for the institution and the hospital, not a workforce that meets Texas’ medical needs.

Added Rep. Mark Shelton, R-Fort Worth, a pediatric infectious disease specialist and author of the House budget rider: “Making sure we have primary care doctors is the most important thing we have to do.”