More than 10 years ago, the Statewide Health Coordinating Council (SHCC) launched several initiatives designed to improve the method for collecting and tracking the number and demographics of health practitioners in Texas. It is impossible to predict and address future needs without that information.
As a member of the SHCC from 1997 until 2010 and someone who chaired the council for the past 14 years, I thought the following excerpt from a recently published “Chairman’s Letter” would be of interest — particularly with health care reform on the horizon, the serious shortage and mal-distribution of doctors and other health care providers in Texas, and the state’s budgetary challenges.
Data have shown year after year that Texas is faced with two clear trends: (1) the population is growing faster than almost any other state in the U.S., and (2) the number of health care providers is NOT keeping pace with that rate of growth.
In addition there continues to be major geographic mal-distributions of health care practitioners across Texas. Border and rural areas face the greatest shortages in numbers of health professionals per 100,000 population. And, in spite of significant advances in technology, regulatory barriers have prevented the deployment of telemedicine and other technologies in medically underserved areas, whether urban or rural.
The facts are simple and sobering:
1. Texas has a shortage of physicians in primary care and specialty care! Although the state has increased both the number of medical schools and the size of medical school classes over the past decade, there have not been significant increases in Graduate Medical Education positions for the training of these graduates in Texas. The lack of funded GME slots results in Texas graduates going out-of-state to do their residencies. Only half of those who leave Texas to train ever return; in contrast, more than 80 percent of those who graduate from a Texas medical school and complete a Texas-based GME program will stay and practice in Texas. Until Texas makes graduate medical education its priority in health education funding, the state will continue to invest in medical students who ultimately will go elsewhere for residency and long-term practice. It simply doesn’t make good economic sense for Texas to educate physicians who will serve other states when the need here is so great.
2. There is also a shortage of registered nurses in Texas, but there is an abundance of licensed vocational nurses. The scope of practice of LVNs has been severely restricted exacerbating the nursing shortage. Moreover, the shortages of nurse educators and graduates persist despite innovative programs funded in recent sessions by the Texas Higher Education Coordinating Board and the Legislature to support faculty salaries, fast-track programs and student scholarships. Attrition rates from nurse education programs are alarming; even more so are the attrition rates from the profession itself, in spite of significant salary increases over the past 10 years.
3. Unfortunately, shortages aren’t limited to physicians and nurses. The workforce in all the other health professions is woefully insufficient to meet current or future demand in Texas. The well-documented shortages are most apparent in border and rural areas and include pharmacists, physical therapists, occupational therapists, physician assistants, behavioral health professionals, clinical laboratory scientists, radiology technicians, and others.
The Texas population is growing faster than any other state, with more than 400,000 people becoming new Texans every year (half by birth and half by legal immigration). The growth in the number of undocumented immigrants is unknown but thought to be quite significant. The high birth rate in Texas demands increased numbers of obstetricians, midwives, nurses, and pediatricians. The number of pediatric sub-specialists in our state is dramatically below the ratio found in the U.S. as a whole.
At the other end of the age spectrum, there is an ever-increasing number of Texans 65 and older with remarkable longevity in spite of poor overall health status. These individuals require primary and specialty care services as well. In addition, aging Texans, like their pediatric counterparts, need a vast array of support services, as well as assistance from therapists, pharmacists, nursing care, and chronic disease management experts.
These demographic pressures are compounded by the anticipated impact of national health care reform. Millions of Texans will be added to the current Medicaid eligibility lists by 2014 and others will enter through discounted purchasing organizations. The demand for health care services could increase by as much as 25 to 30 percent in some areas of our state. This will likely overwhelm an already fragile health system.
As the demand for health care services in Texas grows daily, the question is: How can we meet that demand now and in the future? We must entertain new models of care that improve access. We must also employ more effective health and wellness programs, prevention programs and educational programs to improve health status. The use of technology will also demand new workforce initiatives.
Boldness and innovation in our thinking and practice may be uncomfortable for some, but they are a necessary step toward a healthier Texas. Without the willingness to change, we will find ourselves with a health system incapable of meeting the needs of any of our citizens—young or old, wealthy or impoverished, urban or rural.
In turn, the productivity of our state will be significantly and adversely affected as more and more Texans find themselves unable to work due to chronic and debilitating health conditions. Maintaining current regulatory and scope-of-practice restrictions will not serve us well. Major reforms in education, regulation, scope-of-practice determination and the use of resources MUST be priorities for our state. Simply put, the status quo is not sustainable.
Texas must embrace a serious re-prioritization of resources in health education, and that education must be interprofessional and interdisciplinary. Graduate Medical Education programs must be placed at the top of the financial priority list. We must determine scope-of-practice boundaries using evidence-based criteria and core educational competencies, with standards for quality and public welfare of paramount importance.
Licensure for the practice of medicine must NOT be compromised. Health care education must become less fragmented and include a career matrix so that professionals share broader bases of knowledge that enable them to migrate among different career paths as their interests and the needs of those they serve evolve. We must educate health professionals collaboratively so that they can practice in team-based models in the future.
Texas must align desired health outcomes with financial incentives and rewards for those practitioners demonstrating evidence-based practice and quality outcomes. Priority must be given to maintaining wellness, for prevention and education programs, and for the management of chronic disease in a manner that reduces unnecessary emergency room and hospital admissions.
Every year that our state puts off reforming the health professional education and training process is another year that quality of and access to health services deteriorate. Inaction almost guarantees that future assessments will report increasing shortages in the health care workforce, decreased access to services and erosion in quality of life.
Improving the health of all Texans is about much more than adding a new medical or nursing school. It is about a vision for a future in which health care delivery is a shared community responsibility. It requires us to stretch our imaginations and our comfort zones to embrace new technologies and new models of medical practice.