Health care advocates have for years worried about a shortage of doctors serving rural and low-income Texas communities. But in Austin and the surrounding areas, which have one of the highest doctor-to-patient ratios in the state, there is a different challenge, according to Dr. Jonathan MacClements, assistant dean of graduate medical education at The University of Texas Dell Medical School.

“We really don’t have a physician shortage,” MacClements said. “What we have is a physician distribution issue.”

With the late May opening of the Dell Seton Medical Center at The University of Texas, which serves as a teaching hospital for The University of Texas Dell Medical School, health care educators said they hope new technology and a collaborative, multidisciplinary approach to medical training will offer solutions to address a perceived need for more primary care options statewide.

“We’re really interested in training the next generation of physicians to focus on overall health,” said Christann Vasquez, the new teaching hospital’s president.

Addressing growth
Cedar Park Regional Medical Center works each year to review what needs there are for physicians in the community, according to CEO Brad Holland.

“We recruit physicians to fill that community need for the services that we offer,” Holland said. “When we say we work to recruit and meet that community need, we are not in a vacuum but in partnership with the community physicians in those areas.”

In primary care, for example, Holland said the CPRMC will work with other area providers to bring in physicians rather than have them all be hired through the center. Partners include Austin Diagnostic Clinic and Austin Regional Clinic as well as independent health care providers.

“Our philosophy is to work in partnership with existing providers,” Holland said. “We are not, ‘You’re with us or against us.’”

Faster rise in specialists
Texas ranked 41st among U.S. states in 2015 for its ratio of physicians per 100,000 residents, requiring roughly 13,000 more physicians to reach the national average, according to a study from physician consulting firm Merritt Hawkins.

As the state population has grown during the past 20 years, so has the number of doctors holding licenses to practice in the state, according to data from the Texas Medical Board. However, the statewide growth rate for licensed specialist physicians has risen by 72.55 percent over the past two decades compared to 42.54 percent for primary care physicians, according to the data.

Travis County had a 154.66 percent increase in specialists holding licenses between 1997 and 2017 compared to an 81.96 percent increase in primary care doctors during the same time period. As of January the board counted 2,348 doctors licensed as specialists in Travis County and 1,261 licensed in primary care. Williamson County had a 650 percent increase in specialists holding licenses from 1997-2017 compared with a 303.23 percent increase in primary care doctors in the same time period. In January, Williamson County had 375 primary care physicians and 450 specialists.

Not every licensed doctor may actually be practicing, and some may only work part-time.

Higher pay attracts doctors to pursue specialties, although they require longer training and oftentimes a greater student-debt load, said Dr. Norman Chenven, the founding CEO of Austin Regional Clinic, a multispecialty medical group serving Central Texas.

Specialists also tend to receive better payment for care due to more patients having health insurance, he added. Chenven said doctor distribution issues are more apparent in areas with high numbers of low-income patients who generally lack adequate health insurance, known as the safety-net population.

“For the most part, primary care has been a challenge over the last decade or two,” he said.

Doctors who work within the safety-net population often treat patients with more complex and chronic health care issues as well as experience other cultural challenges and language barriers, said Dr. Alan Schalscha, chief medical officer for CommUnityCare, which operates federally qualified health centers in Travis County to serve low-income residents who often lack insurance coverage.

“If providers don’t have a true passion for the mission, they burn out of the safety-net population really quickly,” Schalscha said.

In terms of physician numbers, Chenven said Travis, Williamson and Hays counties do not face the types of shortages seen elsewhere in Texas and around the country. But without better distribution, the counties will continue to have issues with people of lower income levels not having the ability to access care, he said.

“If you took all the doctors in these three counties, organized them into an efficient delivery system, you have plenty of physician power,” Chenven said. “Plus, you add to that the nurse practitioners and physician assistants, and you’ve got a lot of medical care that can be delivered.”

In addition, large health networks are constantly adding locations to better serve the population.

Holland said CPRMC looks across all of its specialties to determine where shortfalls may lie. He said this can help the center determine what services it needs to continue to offer as well as new ones that could be integrated into the system.

“If [the survey of services] says we need to support interventional cardiology and we need cardiologists, maybe that’s a service we’re ready to get into with our complexities and program development,” Holland said.

Improving care
One strategy Dell Medical School is using to improve distribution of care is to decentralize the residency training the school does with Seton Healthcare Family, MacClements said.

Dell Medical School recently moved its internal medicine program from the former University Medical Center Brackenridge in downtown Austin to Central Health’s Southeast Health and Wellness Center on Montopolis Drive in Southeast Austin, he said.

With its technological capabilities and collaborative design, the new Dell Seton Medical Center is also meant to transform the landscape of medical training and health care delivery in Central Texas, said Greg Hartman, chief of external and academic affairs for Seton Healthcare Family.

MacClements said Dell Medical School’s focus is not just looking at increasing the size of its training programs but also changing its overall approach to health care.

“We literally are rethinking everything,” MacClements said.

Looking forward, Holland said the region continues to see an evolution in outpatient services and “retail access points,” where people seek out health care in a retail setting.

“We are the generation of now. We want access now in a location close to us in a cost-effective manner,” Holland said. “We want to meet that generation of now through those retail access points. We offer acute services in a medical hub, but we also are starting to see development in these access points.”

Nurses seek greater role
For many years, Texas nurse practitioners have sought to expand their role in primary care, arguing that doing so could help alleviate doctor shortages or distribution issues, particularly in low-income or rural communities.

Two bills filed in the 85th Texas Legislature this year—House Bill 1415, filed by state Rep. Stephanie Klick, R-Fort Worth, and Senate Bill 681, filed by state Sen. Kelly Hancock, R-North Richland Hills—proposed to remove state regulations that allow nurse practitioners to treat and write prescriptions for patients but only if nurse practitioners first sign contracts with doctors.

Groups backing the bills, such as the Texas Nurse Practitioners, the Texas Nurses Association, the AARP and the Texas Association of Business, argue that doing away with contracts would encourage nurse practitioners to stay in Texas. They argue Texas-based nurse practitioners have a competitive disadvantage with their counterparts in other states due to the cost of maintaining such contracts.

Opponents of the effort, including the Texas Medical Association, argue that nurse practitioners play important roles in health care, but the lengthier training and deeper expertise required of doctors make contracts necessary in order to keep patients safe.

Both bills were left pending in committee at the end of the Legislature’s regular session in May, meaning the effort to loosen statewide
regulations will have to wait until at least 2019.