RATIONALE AND BACKGROUND

For many years, state officials have been concerned about the overall lack of primary care providers and their maldistribution in Texas. Texas ranks below the national average in the number of generalist physicians practicing per 100,000 population and has a higher percent of its population underserved (11.2%) than the country as a whole (10.5%). As of March 1996, Texas had an estimated medically underserved population of nearly 2 million located in 171 health professional shortage areas (HPSAs). The federal government estimates that about 400 primary care practitioners are now needed to remove these HPSAs (based on a physician to population ratio of 1 physician to 2,000 persons).

On the other hand, Texas fares better than the national average in the percent of physicians retained in the state after training (57%) and in the percent of practicing physicians trained in the state (57%).

In 1987, Texas lawmakers passed a law (SCR 25XX) creating a nine-member "Special Task Force on Rural Health Care Delivery in Texas." The charge of the task force was to: 1) define minimal desired medical care for rural counties and communities, taking into consideration population, geography, proximity to tertiary care centers, physician manpower and transportation availability; 2) define the resources available and/or needed to provide a voluntary plan to meet the needs of the state's counties, including methods of financing the implementation and operation of such a plan; and 3) seek consensus among affected parties to support the plan.

The final report of the Task Force was issued in 1989. In addition to other rural health care issues, the report focused on workforce needs, supporting several changes in the state's current rural health care delivery system to enhance the number of primary care providers in rural and underserved areas. In response, the legislature enacted an extensive law in 1989 relating to rural health, "The Omnibus Health Care Rescue Act," (HB 18).

The 1989 rural health legislation required the Texas Higher Education Coordinating Board (THECB), the newly-established Center for Rural Health Initiatives, medical and other health care education schools to cooperate to improve and expand programs for rural areas, including the following: 1) encourage and coordinate the creation or expansion of a rural preceptor program among medical schools and teaching hospitals; 2) require family practice residency programs to provide an opportunity for residents to have a one-month rotation through a rural setting; 3) the development of relief service programs for rural physicians to facilitate access to continuing medical education; and 4) requires medical schools to incorporate a third-year clerkship in family practice for all medical students and report on its efforts to fulfill the intent of having at least 25 percent of first year primary care residents in family practice. Until recently, Texas was the only state whose legislature required all third-year medical students to complete a clerkship in family medicine.

The rural one-month rotation for family practice residents is required to be offered as an optional site for family practice residents. All medical students must complete a family practice clerkship in a rural setting during their third year of medical school. Legislation has also established a goal that 50 percent of all residency slots be in primary care, of which half should be family practice.

1. SB 1280 approves several new measures to improve the supply of family practice physicians. Among the provisions pertaining to undergraduate and graduate medical education:

a) Establishes new statewide preceptorship programs in general internal medicine and general pediatrics modeled after the existing family practice preceptorship program. THECB receives initial funding to support 200 students annually;

b) Provides an additional $1 million for family practice residency training program (first increase in state funds for the program since 1988);

c) Expanded from three to five those family practice residencies that provide services in economically depressed or rural areas of the state (Senator David Sibley, DDS, JD of Waco authored this provision.);

d) Provides support for an additional 150 community-based primary care residency positions phased in over 5 years; and

e) Restores funding for the Resident Physician Compensation Program, providing partial support for primary care residents training at Texas' 25 primary teaching hospitals.

2. SB 10 authorizes the state to move to a Medicaid managed care system on a county by county basis.

In 1995, Texas' eight medical schools graduated 1,163 physicians, up from 1,013 in 1981. According to a survey of these 1995 graduates by the Texas Medical Association (TMA):

1. Sixty percent of respondents chose to do their postgraduate training in Texas. This is a major reversal from the 1980s when 60 percent of Texas medical graduates left the state for postgraduate education because Texas did not have enough first-year residency positions to meet demand;

2. Fifty-seven percent of respondents chose postgraduate study in the generalist specialties: family practice, internal medicine, pediatrics and obstetrics-gynecology. Forty-eight percent of respondents indicated they intended to practice in these generalist fields upon completion of training; and

3. Thirty-seven percent of respondents completed a preclinical family practice preceptorship; nearly half of these identified family practice as their postgraduate specialty. Students completing family practice preceptorships were 6 times more likely to choose family practice as their specialty than were students who did not participate in a family practice specialty.

In 1995, Texas' 414 allopathic and 29 osteopathic medical residencies graduated about 1,100 residents and fellows. According to a survey of these graduates by TMA:

1. Of the 544 respondents who chose to practice a medical specialty, more than half (55%) trained in the generalist fields of internal medicine (21%), pediatrics (15%) and family practice (11%), and in obstetrics-gynecology (8%);

2. More than half (56%) of the respondents spent the majority of their precollege years in a large city or suburb; just 20 percent lived in a small city or rural community. Only twelve percent of respondents said they intended to practice in a small city or rural community; and

3. In 1994, 61 percent of all first-year residents in Texas’ graduate training programs were in primary care specialties.