Seizing Opportunity

TMA Forum Promotes Graduate Medical Education Expansion

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Education Feature — January 2016 

Tex Med. 2016;112(1):45-50.

By Amy Lynn Sorrel
Associate Editor

The 2015 Texas Legislature wasted no time this session investing more money in graduate medical education (GME) to grow the physician workforce, a priority from the start for medicine, medical schools, and key lawmakers. And the Texas Medical Association wasted no time making sure the money gets put into action.

In November, TMA joined the Texas Hospital Association, the Texas Higher Education Coordinating Board (THECB), and Teaching Hospitals of Texas to host a forum to help hospitals, medical schools, and other entities take advantage of the $53 million in grant money lawmakers authorized to create and sustain hundreds of new residency training slots. That's on top of the $14.25 million the 2013 legislature set aside for GME expansion — money medical schools and hospitals already put to good use to create 100 new first-year positions in 2014 and 2015.

TMA and state officials say the legislative investment marks critical progress toward addressing the bottleneck Texas faces in physician training as medical school graduation rates outpace the number of entry-level residency training slots available. At the current pace, THECB estimates that Texas needs an additional 129 first-year positions in 2016 to achieve TMA and the state's goal of having 1.1 slots per Texas medical school graduate. That number jumps to 687 by 2022. (See "A Widening Gap.")

The grants do more than help secure a pathway for doctors-in-training to enter the workforce. The additional money gives hospitals and academic partners the flexibility to develop innovative ways to increase access to care, says psychiatrist Linda B. Andrews, MD, senior associate dean for GME at Baylor College of Medicine (BCM) in Houston. The grants have allowed the medical school to resurrect or reinvent training experiences that were on the back burner due to lack of funding, including training internal medicine residents in cancer centers and rotating psychiatry residents in community jails. 

"These are training experiences we would not even be thinking about without these grants," Dr. Andrews said. "We get to help the state meet its workforce needs, and we get to expand to training sites we couldn't use otherwise and to develop unique training experiences."

Hospitals say residency training is a core part of their mission, too. Because building GME programs requires intensive commitment, however, and because new hospital sites are critical to growth, TMA's Council on Medical Education organized a forum where experts like Dr. Andrews shared their experiences and encouraged increased participation to get more residency programs off the ground. 

With Texas' exponential population growth exacerbating the state's need for more doctors, "fortunately, the legislature understood this [capacity] issue and gave us the resources to address it," said Jonathan MacClements, MD, a member of TMA's medical education council and forum host. He is assistant dean of GME at The University of Texas at Austin Dell Medical School.

Building Blocks

GME expansion was the top priority for medicine this past legislative session, and thanks to years of advocacy, the issue was top of mind for lawmakers, too. With federal funding frozen for hospitals that already have GME, TMA leaders and Texas educators urged the state to double down on its commitment.

Lawmakers answered with nearly quadruple the $14.25 million allocated for expansion in the 2014-15 budget. The major vehicle to put the $53 million into action starting this year is Senate Bill 18 by Senate Finance Committee Chair Sen. Jane Nelson (R-Flower Mound) and Sens. Juan "Chuy" Hinojosa (D-McAllen) and Kel Seliger (R-Amarillo). Rep. John Zerwas, MD (R-Richmond), sponsored the House version. The boost builds on medicine's successes in 2013 after lawmakers slashed GME funding during a 2011 budget crisis. 

"We've come a very long way, and we look forward to continuing the wonderful efforts made to expand GME," said Stacy Silverman, PhD, THECB deputy assistant commissioner for academic quality and workforce. "This was an effort on behalf of TMA and all the medical schools to help the legislature understand how important it is to fund GME because the reality is, we don't want to be a state that educates physicians and sends them away. And that was recognized." 

SB 18 streamlines and expands the GME grant programs created in 2013 and includes:   

  • Planning and partnership grants to help nonteaching and teaching hospitals, medical schools, and community-based centers (such as federally qualified health centers and teaching health centers) explore the feasibility of starting new residency programs;
  • Funding for accredited but unfilled first- and second-year slots; 
  • Money to expand existing or build new GME programs; and
  • Continued support for new positions created in 2014 and 2015.     

SB 18 also increased the funding levels for the planning and partnership grants from $150,000 to $250,000 and for new and expanded first-year positions from $65,000 to $75,000 per resident, per year. The goal is to fill new training spots no later than July 2017, accounting for the time it takes to get new programs up and running and accredited, THECB officials say. 

At the time of this article's writing, medical schools and hospitals were on task to apply for GME expansion grants that build on the momentum started last session. THECB expects to announce the awards in January and start distributing money this spring, after the national resident Match Day results are in and programs know how many residents they will accept. Applications for the planning and partnership grants likely will open up in March for awards later this spring. (See "Resources.")

Easing some concerns over the legislature's long-term commitment to GME growth, SB 18 establishes a permanent state GME fund, with some initial monies coming from the Texas Medical Liability Insurance Underwriting Association (JUA). (The insurer-of-last resort provides affordable medical liability insurance to physicians unable to obtain it elsewhere in the private market.) SB 18 put the Texas Department of Insurance in charge of a JUA audit and potential funds transfer, which was still under way at press time.  

Still, some hesitations linger. Unless lawmakers renew their commitment, schools and hospitals expressed concern the two-year funding cycles set up for the grant programs will run out long before the duration of residents' training, which typically lasts three to four years, longer for certain specialties. 

The latest grant awards would support filled positions for two complete GME academic years from July 1, 2016, through Aug. 31, 2018.

TMA officials have raised concerns, too, that a reduction in the Texas JUA budget reserves would draw lawsuits if any money is redirected away from JUA policyholders. Legal action successfully halted other states’ raids on similar medical liability funds to plug budget holes.

Dr. Silverman says lawmakers have indicated to THECB that the expansion grants and their funding are meant to be long-term programs. Because there are no guarantees, however, and because the state is confined to a two-year budget cycle, "it's important to continue to let the legislature know how important that funding is." 

Feeding the Physician Pipeline 

The 2013 grant programs opened up 100 entry-level residency slots, and the 2015 programs are expected to add at least another 200 new positions for medical school graduates on their way to becoming physicians in the nation's fastest-growing state. 

The planning and partnership grants, for example, are meant to help hospitals, medical schools, and community-based ambulatory patient care centers determine the feasibility of establishing first-ever GME programs per Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) standards. For nonteaching institutions, the process can involve everything from building the infrastructure to host residents, to budgeting for resident and faculty salaries, to preparing for and passing accreditation reviews focused more intensely on quality improvement and patient safety.

Higher standards and more diverse patient populations mean "residency training is tremendously different now," making the start-up process quite labor-intensive, said Robert J. Nolan Jr., MD, a pediatrician and associate dean for GME at The University of Texas Health Science Center at San Antonio.

But broader eligibility rules under SB 18 now make it easier for academic institutions to partner with smaller community hospitals to plan new GME programs and get more physicians in rural areas that may not otherwise have the resources for the intensive process, says Courtney Dodge, assistant dean and director of GME at the Texas A&M Health Science Center College of Medicine in Round Rock.  

Texas A&M collaborated with DeTar Healthcare System in Victoria, which won a planning grant in 2014 to explore a family medicine residency program at the hospital. 

Mr. Dodge said DeTar already was committed in principle to a GME program. But because starting from scratch is not easy, he said, "it surely helped to have the nudge the $150,000 planning grant provided."

The effort paid off: DeTar later won a separate state grant of $390,000 to start six new family medicine residency positions, "and now we are well on our way to getting those residencies fully funded," Mr. Dodge said. 

Hospitals that never had a GME program before can pursue additional Medicare dollars to sustain new residency positions. But with a federal limit on the number of existing slots the Medicare program will fund, state money is especially critical to help programs stymied by the 1997 cap. 

"We all thought, certainly this [Medicare cap] was temporary. But here we are 18 years later, and it's not temporary," Dr. Nolan said.

Houston Methodist Hospital System had plenty of room to host more internal medicine residents but, because of the Medicare cap, could not afford the expense. Vice President of Education Administration Trevor Burt says the extra state money came in handy to fill seven new slots, and the sponsoring institution has since identified five "untouched" community hospitals without GME as potential new partners going forward. 

"Now we have the ability to look even further out at what kind of growth opportunities are out there and new partners in the state to help us. So this opens a door, being over the cap, and it all comes back to benefit us," Mr. Burt said. 

Dr. Andrews emphasizes another advantage of the state grants over Medicare GME funds is greater latitude in supporting residency positions where they are needed, including outside of hospitals. "The grants link funding directly to GME positions rather than to training locations, which allows sponsoring institutions and hospitals to create positions above hospital caps and allows program directors tremendous flexibility to design the absolute best possible training for their residents."

An expansion grant helped BCM develop a collaboration with The University of Texas MD Anderson Cancer Center to train internal medicine residents in hospitalist oncology, adding 15 first-year residents to the program over the next three years, five per year. BCM's psychiatry residency program also hopes to receive a grant allowing psychiatry residents to train in community jails and outpatient psychiatry facilities, which Dr. Andrews says will offer "invaluable training for residents and mental health services to the state. And this is all driven by the state's interest in expanding primary and psychiatric care."

A portion of the grant money prioritizes primary care and psychiatry programs, but awards are not limited to those specialties. Most of the 2013 grants went to primary care training, but other awards included anesthesiology, emergency medicine, neurology, and surgery programs, among others. 

Dr. Andrews adds that Texas' precedent-setting efforts have caught widespread attention. She recently attended a meeting sponsored by the National Resident Matching Program, where members of an Institute of Medicine (IOM) committee that recently reviewed the current GME system praised the Lone Star State's initiative to tackle GME shortfalls. (See "GME Gamble," October 2014 Texas Medicine, pages 27-31.) 

"Texas is already doing things the IOM GME report says we should do to increase GME," such as directly linking funding to GME positions versus training locations, she said. "That is a great affirmation."

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.



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