FORT WORTH -- The Supreme Court's decision upholding the Affordable Care Act could give millions of uninsured Texans access to healthcare. But that access will mean little if too few people are available to deliver care.
The doctor and nurse shortage is a problem for Texas and the nation.The state's forecasts put Texas 71,000 nurses short of the number it needs by 2020. A workforce study by the American Academy of Family Physicians estimates that the country will need 39,000 more family physicians by 2020. The need is particularly great in Texas, which ranks 47th among states in active primary-care doctors for its population.The law, which reaches full strength in 2019, shifts the healthcare focus toward prevention, making primary-care workers even more important as it highlights workforce deficiencies.The act will channel people who once entered the healthcare system through emergency rooms into clinics and doctors' offices, where preventive care is emphasized, Tarrant County Commissioner Roy Brooks said. But the people who will deliver care from those offices, clinics and community healthcare storefronts are not in the pipeline."This healthcare reform bill is the first in a long chain of actions that will be needed to bend the healthcare cost curve in this country and provide access to medical care to all our residents," Brooks said. "The requirements of the act itself will force the system to react in certain ways, and one of the inevitable reactions is that we will have to have a highly trained workforce to help make this system work. We will have to go into a training mode that will require the participation of all of our educational resources."G. Sealy Massingill, president of the Tarrant County Medical Society, also doubts that the system will be ready in time to serve the millions of consumers who will access the healthcare system at new entry points. Tarrant County will be 10 to 15 percent short of the primary-care physicians needed.That's fortunate compared with some other counties, Massingill said.Obstacles to overcomeTexas has struggled in the past decade to increase working primary-care doctors and nurses, but it has met roadblocks.One is that too few residency slots are available for first-year medical school graduates, Massingill said.Last year, 1,404 people graduated from medical schools in Texas, but there were only 1,390 residency slots, said Gary Floyd, vice speaker of the medical association's House of Delegates.And each year the gap is expected to grow, Floyd said. That's a loss for the state because educating a primary-care doctor costs $300,000 to $400,000, he said."We train people. Then we send them out of state," Floyd said. "Once we send them out of state, it's very difficult to get them to come back."The Affordable Care Act provides $250 million in new funding to expand the primary-care workforce, including more residency slots at hospitals and more training for nurses.Another roadblock is the amount of money that doctors are reimbursed by Medicare and Medicaid. Reimbursements are so low that some doctors will not take new patients who are in the government healthcare programs."People will have a card that says they can get healthcare, but they may not be able to find anyone who is willing to accept it," Massingill said.To address the problem, Congress included a bonus program for select services provided by primary-care doctors.Still, Texas can't catch up with the need for some time, said Don Peska, dean of the Texas College of Osteopathic Medicine, part of the University of North Texas Health Science Center at Fort Worth. To close the gap, resources that were directed at emergency rooms should go to ambulatory clinics and primary-care and family physicians, Peska said.So rather than 6 million more people being funneled into hospitals, they will come into the system differently, Peska said.The med schools' partTo address the shortage of primary-care physicians, medical schools are trying to reduce costs and the time to graduate."An excellent example is a three-year program for primary care they are doing at Texas Tech," Peska said. "We are duplicating that strategy. It will allow both of us to get doctors into the system sooner."Clair Jordan, Texas Nursing Association executive director, said she wants to work with doctors and lawmakers to remove or ease restrictions on advanced nurse practitioners and physician assistants to get them into the system sooner and place them where they can be the most efficient.The University of Texas at Arlington has created patient simulation labs that let nurses get through clinical training faster, she said. The healthcare law will require a lot of out-of-the-box thinking so people can look at traditionally trained professionals in new ways.The demand will not slow for those professionals, but they can be used so as to provide more services to more people, Jordan said.In great demand, she said, are nurse navigators: nurses who attach to people grouped by diagnosis, such as congestive heart failure, and guide them through steps to staying out of the hospital."The major thing that needs to be done with healthcare is that costs need to be reduced, quality needs to be elevated and access needs to be expanded," Jordan said. "Nursing is an answer in any conversation that you have when you talk about delivering healthcare in new ways."There are a lot of opportunities to address these shortages, said Steve Newton, president of Baylor All Saints Medical Center in Fort Worth. Exploring telemedicine, using physician assistants in novel ways and working with nursing schools to widen the pipeline for the best and brightest are needed approaches, Newton said."The shortage that we feel today will feel even more acute in the short term," Newton said. "But all of us in healthcare are being asked to do more with less. Through advances in technology and better coordination, we can do more with less."Mitch Mitchell, 817-390-7752Twitter: @stcrime