Ashley S. and her husband were ready to start a family.
Or at least, they thought they were.
The Fort Worth couple had been trying to get pregnant until they received some concerning results from genetic testing.
Ashley, who prefers to only use her first name because she works in the healthcare industry, found out that she has a gene mutation that puts her at risk for miscarriage and her children at risk for birth defects.
When she tried to make an appointment with her obstetrician/gynecologist last fall, the first available appointment was not until February.
“I ended up calling every two weeks until I got an appointment through someone’s cancellation in January,” she said.
Ashley’s experience is a common symptom of the physician shortage in Texas, where there are 63,871 practicing doctors serving a population of 28 million. The results are often long wait times for patients to get appointments and limited access to healthcare.
What is a physician shortage?
The people most often affected by the shortage are in rural areas with little to no access to healthcare institutions. But even patients like Ashley, who live in metropolitan areas, suffer when their options are limited.
Ashley, 29, is covered by Blue Cross Blue Shield through her employer but she said that not all doctors accept her insurance plan. Even if she were able to find another OB-GYN within the network, the wait times would have been just as long.
There is a nationwide shortage of physicians with nearly 991,000 doctors for a U.S. population of 325 million, according to the Kaiser Family Foundation. In 2018, the American Association of Medical Colleges (AAMC) projected that the United States could see an additional shortage anywhere from 42,600 to 121,300 physicians by 2030.
The Texas Department of Health and Human Services predicts that the state could see a shortage of 3,375 primary care physicians by 2030, a 67 percent increase. Primary care includes doctors with specialties in family medicine, general practice, internal medicine, obstetrics and gynecology, and pediatrics.
Accessing healthcare can be particularly difficult for people in Texas, which has the highest uninsured rate in the country at 17 percent.
A 2016 survey by the Texas Medical Association found that only 45 percent of physicians accepted and treated patients with Medicaid. Texas is also a state that didn’t expand Medicaid coverage, meaning that some people might make too much money to qualify for the program but not enough to afford private insurance.
The state also leads the nation in closures of critical access hospitals, which provide essential health services in rural communities, by closing 16 hospitals since 2010. It now has 85 critical access hospitals. Data about the state physician workforce from the Texas Medical Board shows that 25 counties in Texas don’t have a single physician.
Tarrant County is one of the five counties in the state where most of the doctors are concentrated. However, the Northside, East Fort Worth and parts of Arlington have been designated medically underserved areas by the U.S. Department of Health Resources and Services Administration.
A study commissioned by the nonprofit healthcare provider North Texas Area Community Health Center (NTACHC) found a shortage of 110 primary care physicians and 30 OB-GYNs in the areas the organization services, which include the Northside, East Fort Worth and parts of Arlington.
This often leaves patients with two options: either go to the emergency room where they’ll be seen the same day but rack up expensive bills or wait to see a doctor later for a worsening condition that could also result in expensive treatment.
Ashley is a nurse, and she said understands the frustration the shortage causes from both sides.
“I see patients complaining about wait times but I also see physicians constantly working, and trying to spend the most time with patients,” she said. “They don’t take lunch. The paperwork behind [providing care] takes twice as long as seeing a patient.”
A residency shortage
Heather DeVille knows what a physician shortage feels like.
She grew up in Sugartown, Louisiana, where the 2017 American Community Survey estimates the population to be 78.
The town had two primary care physicians, DeVille recalled, and they were the “good ol’ boys” in the sense that everyone knew them and trusted them. But to see a specialist, a patient would have to drive at least an hour or two away.
“The innovation that they need to move medicine forward in small communities just wasn’t there,” DeVille said. “It did not reach where we lived at that time. It still doesn’t.”
DeVille is a first-year medical student at the Texas College of Osteopathic Medicine (TCOM) in Fort Worth. She knows that she wants to be a specialist herself and is torn between pediatric otolaryngology and pediatric anesthesiology. She’s a single mother who lived in Austin and Houston before coming to Fort Worth. She said she would be happy to practice in Texas.
She’s already started researching residency programs but found that there are few slots in Texas for her interests. DeVille is working toward a Doctor of Osteopathic Medicine (DO) degree. An estimated 90 percent of U.S. physicians hold a Doctor of Medicine (MD) degree. Both degree programs are similar in training but differ in medical philosophy.
After students graduate from medical school, they must complete at least three years of training under the supervision of an attending physician who is ultimately responsible for the patient.
However, Texas isn’t creating more residency positions at the same rate it’s educating and graduating medical students. According to data from the Texas Higher Education Coordinating Board, there were 1,888 first-year residency slots in the state. But AAMC statistics show that Texas graduated 1,517 medical students in the 2017-2018 academic year. They’re part of the 19,553 medical students graduated across the country.
Texas ranks fifth in the nation for physician retention after residency, meaning that 60 percent of doctors stay in the state after their required training. However, because students are competing for residencies with applicants nationwide, a shortage forces students to move to other states if they don’t get a residency in Texas, and are less likely to return afterward. They might also seek residencies elsewhere based on personal interests.
Who pays for residencies?
The shortage in residencies –also known as graduate medical education (GME)– is partially due to the way they’re funded, which is through Medicare. According to AAMC, Medicare is the largest single program to provide support for GMEs.
That federal funding covers resident salaries, and residents make anywhere between $40,000 and $60,000 a year since they aren’t fully licensed physicians.
Medicare also covers a portion of other costs necessary to educating a resident physician, such as malpractice coverage; the extra clinical tests a new, unsure resident physician might order; training programs and accreditation fees.
AAMC estimates that in 2016, the average cost to to train one resident in the U.S. was $169,280. Local hospital district taxes, patient care revenues, and private donations are other forms of revenue cover the remaining costs. Sometimes residency positions can also go unfilled if a health institution cannot afford to fund them.
In March 2018, the United States Government Accountability Office found that the federal government spent $14.5 billion and 45 state Medicaid agencies spent $1.8 billion in funding residencies in fiscal year 2015.
Limited funding is due to the fact that in 1997, Congress capped how many residency positions it would fund every year at 100,000.
Dr. Latasha Jarrett, an OB-GYN and the chief medical officer of NTACHC, pointed out that it takes at least 12 years to become a practicing physician: four years of undergraduate education, four years of medical school and four to seven years of residency depending on the specialty.
So, becoming a physician is costly and students accumulate debt in pursuit of a career in medicine. At TCOM, the cost of attendance for first-year in-state students is about $50,000 a year.
When medical students look for residency programs and jobs, Jarrett said earning potential and the ability to pay back student loans is a huge consideration.
This partly explains why 60 percent of Texas’s doctors practice in and around the state’s urban cities, like Houston, Dallas, San Antonio, Fort Worth and Austin. This leads to shortages in the state’s rural areas like West Texas or the Panhandle.
Population and legal limitations
Another factor is rapid population growth.
With more people moving to Texas every year, there’s an increased need for healthcare. At the same time, Texas has an aging population that will require more regular doctor’s visits. Texans 65 years and older make up 11.7 percent of the population (or 3.2 million people), according to the 2017 American Community Survey. That aging and population growth will outpace the rate at which Texas adds physicians to the workforce, said Dr. Janis Orlowski, AAMC’s chief health care officer
Dr. Deane Waldman, a retired pediatric cardiologist and the director of the Center for Health Care Policy at the Texas Public Policy Foundation, however, points to a legal barrier that prevents people from accessing care. He said the shortage is more a question of the state using the resources it does have to its full potential.
The Texas Administrative Code bars advanced practice registered nurses (APRNs) from practicing medicine to the full extent of their training. Part of the code restricts APRNs from prescribing medication without Prescription Authority Agreement (PAA), where the attending physician would essentially delegate prescription authority to the APRN.
A PAA is easy to obtain in large medical centers that will pay for it. But for APRNs who wish to practice in rural or medically underserved areas, this can cost tens of thousands of dollars. Twenty-three states currently allow APRNs to practice without physician oversight.
“A real problem in Texas is that we don’t allow APRN from going out and taking care of patients in independent practice,” Waldman said. “The excuse is for the safety of the patients. I reviewed 128 [journal articles and studies] and found no evidence of [putting patients at risk]. The bottom line is that as long as they don’t exceed the scope of their training, it’s completely safe.”
Are there any solutions?
When Cynthia Solano called a doctor’s office in Burleson to get a prescription refilled, she figured that if a doctor couldn’t see her that day, she could probably get an appointment the next day or later in the week. Instead, she learned it would take more than a month.
Solano, 25, is asthmatic. She knows that when she starts to feel short of breath, she needs to use her inhaler right away, before it gets worse or becomes a full-on asthma attack.
“I feel like I have a few seconds before I pass out,” Solano said. “I start getting headaches, my vision blurs, it’s the worst. After a while it’s like, a fish without water.”
So rather than wait a month, Solano - who was unemployed and didn’t have insurance - went to the emergency room.
When she finally did get to see a doctor, she said it was fast-paced. The doctor wrote her a prescription and she was sent on her way.
“It’s really hard because you’re waiting for such a long period of time and then with the provider or the doctor, you’re there for maybe 30, 40 minutes,” Solano said. “And then they hit you with this big bill.”
It’s possible that if Texas had removed the PAA barrier, like Waldman suggests it should, Solano would have been able to receive care faster.
Seeing an advanced practice registered nurses would have been cheaper as well. Solano was billed $900 for that emergency room visit.
Today, she works as a patient assistant representative at the Northside Community Health Center, one of the three centers that’s operated by NTACHC in Tarrant County. It was founded by residents and professionals who were concerned about the limited access to healthcare. There, she checks patients in and out and verifies their insurance.
NTACHC also offers sliding scale, meaning that the cost of patients visits are determined by their income if they don’t have insurance.
Like NTACHC, CareMore Health in Fort Worth serves the local Medicare and Medicaid populations. The organization was founded in 1993 by physicians in Southern California to provide an alternative clinical model to healthcare by focusing on preventative care and offering both physical and behavioral health services. CareMore Health operates in eight states and Fort Worth is its only Texas location.
Texas officials are well-aware of all of these roadblocks in serving its population. In 2017, the state legislature increased its designated funding to create more first-year residency positions to $97.1 million, in addition to federal Medicare funding.
It also passed a bill to enable healthcare professionals to practice telemedicine. Waldman said with the right technology and setup, this would allow nurse practitioners to serve rural communities as long as they have access to physicians and specialists who are based in big cities.
So far, Rep. James White (R-16) has introduced legislation to allow APRNs to practice with less oversight in certain rural counties.
Rep. Matt Shaheen (R-66) represents West Plano and Far North Dallas. He and Waldman are working on legislative reforms to expand access to healthcare across the state.
“One thing is we’re working on is legislation that specifically expands healthcare access for the needy,” Shaheen said. “It gives counties the authority to reduce county property taxes of a physician that agrees to provide healthcare services for free and [agrees] not to seek reimbursement.”
Shaheen said that if passed, the change would create a situation where low-income patients are treated like everyone else. A doctor would receive some monetary benefit and would have much less insurance-related paperwork to fill out.
Another solution Shaheen has proposed is to allow doctors to dispense certain medications to patients in their offices. This way, if a patients come in with an easily diagnosable problem – like strep throat or asthma – they can receive medication in that same visit, rather than going to a pharmacy and prolonging their illness.
The recently-accredited TCU and UNTHSC School of Medicine in Fort Worth will welcome its first class of students this summer. Those in the inaugural class won’t pay tuition the first year and will instead be funded by donations, somewhat lessening the burden of debt.
As a requirement, and keeping in mind that physicians tend to stay in Texas after completing residency here, Senate Bill 1066 requires any new medical school to “provide a specific plan regarding the addition of first-year residency positions for the graduate medical education program to be offered in connection with the new degree program.”
In compliance, Medical City Healthcare pledged to create 500 residency positions in its 14 hospitals around the Metroplex over the next seven years. UNTHSC will be the academic sponsor.
Until the opening of the TCU and UNTHSC School of Medicine, TCOM was the only medical school in Fort Worth and only offers DO degrees. The city was the largest in the country without a school conferring MD degrees.
The Texas Higher Education Coordinating Board also offers student loan forgiveness programs that require participating residents to complete at least four years of their training at a federally qualified health center, which are typically in medically underserved areas. NTACHC hosts some of these resident physicians.
Acknowledging that need for rural doctors, UNTHSC created a pipeline program with Midland College to educate students who are interested in serving that community, where the number of physicians hasn’t kept up with the population growth.
Dr. Michael Williams, the president of UNTHSC, said the university was approached about how to keep doctors in Midland County.
“The reason we got into the whole rural health piece was because it was a big need,” Williams said. “We think our mission as a university is to create solutions and building a healthier community, which is Texas, and so as a result of that we look at ways to address the major needs of Texas.”
The Rural Medicine program at TCOM also recruits students who are either from rural communities or passionate about serving one. In addition to standard medical school classes, rural medicine students are required to complete their rotations outside of DFW to fully understand and immerse themselves in a rural community.
According to Waldman, many doctors choose to become specialists because they make more money and they have student loans on their mind. He said that with all these obstacles, access to healthcare in undeserved areas partially depends on the doctor’s interests and passion to practice medicine.
“If you like being in primary care and you like being involved in the lives of your patients, you’re going to have trouble with that in downtown Dallas,” Waldman said. “But if you’re the only doctor in West Texas, you’re an integral part of the community and there’s a sense of satisfaction that you can’t get any other way.”
Ashley said that after of all of this, she and her husband are trying for a baby again. But she’s taking all of her healthcare into her own hands.
When the day of her OB-GYN appointment finally came, she waited about an hour because the doctor was running behind schedule. She was able to ask all the questions she wanted to but still has to find a specialist to help her through her specific problem.
After the appointment, she was asked if she wanted to schedule an appointment in January 2020 on the same day. She said no, and instead wanted an appointment three months later to follow up. After some back and forth, she was able to get scheduled for the day she wanted.
“It was like pulling teeth to get that,” Ashley said.