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1 April 2015 THE PHYSICIAN WORKFORCE IN TEXAS An Examination of Physician Distribution, Access, Demographics, Affiliations, and Practice Patterns in Texas 254 Counties Prepared for North Texas Regional Extension Center by: Copyright 2015 NTREC APPENDIX A ACO Facilities Supported by Grant Number EP-HIT from the Office of the National Coordinator, Department of Health and Human Services.

2 THE PHYSICIAN WORKFORCE IN TEXAS An Examination of Physician Distribution, Access, Demographics, Affiliations, and Practice Patterns in Texas 254 Counties TABLE OF CONTENTS Introduction... 1 Key Findings... 3 Physicians by County... 4 Severe Shortage Areas and Specialties Low Physician Ratios and Maldistribution Health Professional Shortage Areas A Growing Supply of Physicians State of Primary Care A Shortage of Specialists Physician Retention in Texas Diversity Challenges A Growing Demand for Physicians Physician Practice Patterns/Effects on Access Impact of Physician Age Physician Morale in Texas Impact of Gender Team-Based Health, PAs and NPs Employment, Consolidation and Affiliations Population Management and Accountable Care Organizations Meaningful Use Conclusion APPENDIX HPSA Designated Counties and Service Areas In Texas... Urgent Care and Walk-In Clinics in Texas... Hospitals in Texas With Affiliated Physicians... A B C Merritt Hawkins Project Team: Project Manager Lead Author Research Director Research Associate Travis Singleton, Senior Vice President Phillip Miller, Vice President, Communications Samantha Avila, MHA, Project Specialist Garrett Garber, Corporate Communication Specialist

3 THE PHYSICIAN WORKFORCE IN TEXAS An Examination of Physician Distribution, Access, Demographics, Affiliations, and Practice Patterns in Texas 254 Counties INTRODUCTION What is the state of physician distribution and access in Texas 254 counties? How are physician practice patterns, demographics, affiliations, employment status, electronic health record (EHR) implementation, Medicare and Medicaid acceptance rates and other practice characteristics and metrics evolving in the state, and how will these changes affect patient access to care? Merritt Hawkins, a national physician search and consulting firm and a company of AMN Healthcare (NYSE: AHS), was commissioned by the North Texas Regional Extension Center (NTREC) to complete a physician demographic study examining these and related questions. This report and its Appendices and accompanying Excel sheet data sets delineate our findings and analysis. About North Texas Regional Extension Center and DFW Hospital Council Foundation A program of the DFW Hospital Council (DFWHC) Foundation (www.dfwhcfoundation.org), the North Texas Regional Extension Center (NTREC) assists physicians in 42 counties in implementing Electronic Health Records. NTREC was funded by a 2010 grant from the U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. The DFWHC Foundation is a non-profit 501(c)(3) organization with a mission to continually improve the community s health by promoting high quality and cost effective healthcare. About Merritt Hawkins Established in 1987, Merritt Hawkins is the largest physician search and consulting organization in the United States, working with hundreds of hospitals and other healthcare facilities each year nationwide. Merritt Hawkins also conducts internal research for the benefit of its clients and external research on behalf of third parties interested in physician demographics, physician practice patterns, community needs assessment, and related topics. Merritt Hawkins has conducted external research for a variety of organizations, including The Physicians Foundation, a non-profit group of over 20 state medical societies, the Indian Health Service, Trinity University s Department of Health Care Administration, the Association of Academic Surgical Administrators, and a variety of hospitals and hospital systems. A State of the Union The purpose of this study is to gain a better understanding of the current disposition of physicians in Texas - where they are located, in which specialties they practice, whether they are employed or are independent, whether they are affiliated with larger entities, what types of patients they see, their morale levels, practice patterns, future practice plans and other characteristics likely to affect access to quality patient care in the state. The intent is to present a state of the union of the medical profession in Texas that NTREC may use to evaluate the state s total physician workforce in the context of its mission to ensure the meaningful use of information technology in support of physician practices and thereby enhance patient access to physician services. A Range of Data Following in this report are data collected on the 254-county area of Texas obtained through various public and proprietary sources as collected and evaluated by Merritt Hawkins. This data include physicians by name, specialty, NPI ID, group practice name or affiliation, employment status, Medicare and Medicaid acceptance rates, Meaningful Use payments, and related metrics. 1 P a g e

4 The service area examined in this report includes 254 Texas counties depicted in the map below: In the following sections of this report, Merritt Hawkins will quantify the number and distribution of physicians in Texas and compare them to national averages. We will examine the physician workforce in the state by age, gender and practice patterns and project how these factors may affect physician availability. Merritt Hawkins also will examine Medicare and Medicaid rates of acceptance in the 254- county area to determine potential access to physicians among patients covered by these government programs. Merritt Hawkins will further examine the disposition of physicians in Texas, providing an estimate of the percent that are employed by or affiliated with various entities and the percent that remain independent. The goal will be to provide both fresh and accessible data reflecting provider numbers and affiliations of physicians in the state, and an analysis of how these numbers may affect accessibility to care and the potential need for additional providers. Accompanying this report is an electronic spread sheet listing the majority of physicians in Texas by various fields, including name, specialty, practice status and others. 2 P a g e

5 KEY FINDINGS The study reveals a variety of characteristics about the physician workforce in Texas of particular note, including: Approximately 63,000 licensed physicians reside in Texas. Of these, 46,953 are in active patient care and this is considered the net physician workforce in the state in this report. They serve a population of 26,448,193 Texas residents. Texas ranks 41st among the 50 states in active patient care physicians per 100,000 population. It would require 12,819 additional physicians to bring Texas in line with the national average of physicians per 100,000 population. Texas ranks 47 th in the nation in active primary care physicians (PCPs) per 100,000 population. 35 Texas counties have no physicians of any kind. 80 Texas counties have five or fewer physicians. 147 Texas counties have no obstetrician/gynecologist. 185 Texas counties have no general psychiatrist. 158 Texas counties have no general surgeon. The physician workforce in Texas is disproportionately located in the five most populous counties in the state (Harris, Dallas, Tarrant, Bexar, Travis). 26,620 physicians (57% of the total workforce) practice in these counties, though only 44% of the state s population resides in these counties. Smaller counties of 40,000 people or less are home to 2,264,257 Texans (8.6% of the state s population), but only 1,170 physicians (2.5% of the total workforce) practice in these counties. There is a ratio of only 52 physicians per 100,000 population in counties of 40,000 people or less in Texas, compared to 228 per 100,000 for the five most populous counties and 183 per 100,000 for the entire state. Though it has a relatively low ratio of physicians per population, Texas is one of the few states where growth in the physician workforce is matching or exceeding growth in the general population. Since the passage of tort reform in 2003, Texas has licensed an average of 3,200 new physicians a year. Emerging practice patterns and practice choices among Texas physicians are likely to erode access to physician services in the state, as 45% of Texas physicians plan to accelerate their retirement plans, 19% plan to cut back on hours, 9% plan to switch to concierge practice, and 6.4% plan to work part-time. Texas physicians have little capacity to take on extra work or see more patients. Over 78% of Texas physicians indicate they now are at full capacity or are overworked and overextended. A relatively high number of Texas physicians remain in independent practice, but a growing number are employed or are affiliated with larger entities. Between 45% and 49% of Texas physicians are independent practice owners, compared to approximately 35% nationally. Texas has the highest number of physicians in solo practice (29%) of any state. Medicare and Medicaid acceptance rates are relatively low among Texas physicians. 35% do not accept Medicaid and 20% do not accept Medicare, compared to 18% and 13% of physicians nationally. Texas ranks 43 rd in number of physicians participating in the state insurance exchanges established by the Affordable Care Act (ACA). Texas ranks 39 th in number of physicians participating in Accountable Care Organizations (ACOs). The professional morale of Texas physicians is relatively low, 46 th out of 50 states, a fact that has significant implications for healthcare access and quality. 3 P a g e

6 As these and other data show, the physician workforce in Texas is characterized by a deep divide between rural, low population density areas, where physician access can be minimal to non-existent, and urban/ suburban, high population density areas, where physician access can be comparatively more robust. However, even within more populous regions, there are areas where physician-to-population ratios are low and physician access can be problematic. In addition, the physician workforce in Texas is in transition, maintaining a comparatively large number of independent doctors, but moving toward the employed and affiliated practice models. This unsettled status has led to a paradox a rapidly growing physician workforce with doctors being attracted to the state, yet one where morale is low and where a significant number of physicians indicate they plan to alter their practice styles in ways that may affect access to services in the state. These evolving physician practice patterns, including rates of Medicare and Medicaid acceptance, as well as changing physician demographics, will further limit access to physicians in Texas, where physician-to-population ratios already are low relative to national averages. These trends are examined in more detail below. PHYSICIANS BY COUNTY The physician workforce in Texas is comprised of 46,953 doctors in active patient care, as tracked by the American Medical Association s Physician Master File, the most comprehensive data source of physician numbers and distribution in the industry. The numbers in the chart below are taken from this data set. Merritt Hawkins also uses a robust subset of this number (39,200 physicians) for which detailed data is available through the AMA Master File and SK&A, one of the leading healthcare database companies in the United States, to track information on the employment status of doctors, practice affiliations, Meaningful Use, NPI ID, and related data and metrics. An Excel spread sheet tracking this data is included with this report. Physicians in Texas represent approximately 6% of the 750,000 physicians in active patient care in the United States, while the Texas population of 26,299,463 represents 8.4% of the United States total population of 316 million (AMA Physician Master File/U.S Census Bureau). By 2019, the population in Texas is projected to grow by 11% to 29,094,644, if recent population growth patterns remain consistent. The chart below lists Texas current population per its 254 counties, its projected population to 2019, and its current physician population by county: Texas Service Area by Population, Projected Population and Current Active Physician Population County Population (2013) Population Estimate (2019) Current Physician Population Anderson 57,938 56, Andrews 16,799 21, Angelina 87,441 88, Aransas 24,356 26,889 6 Archer 8,681 7,969 7 Armstrong 1,949 2,046 0 Atascosa 47,093 51, Austin 28,847 29, P a g e

7 Bailey 7,114 7,014 3 Bandera 20,601 20, Bastrop 75,825 79, Baylor 3,614 3,397 3 Bee 32,799 34, Bell 326, , Bexar 1,817,610 2,035,723 4,808 Blanco 10,723 11,688 6 Borden Bosque 17,855 17,141 8 Bowie 93,487 95, Brazoria 330, , Brazos 203, , Brewster 9,286 9, Briscoe 1,537 1,349 1 Brooks 7,237 7,266 0 Brown 37,749 37, Burleson 17,169 17,135 6 Burnet 43,823 46, Caldwell 39,232 41, Calhoun 21,806 22, Callahan 13,525 13,498 5 Cameron 417, , Camp 12,413 12,438 5 Carson 6,010 5,673 0 Cass 30,331 30,088 9 Castro 8,030 7,966 3 Chambers 36,812 40,420 5 Cherokee 50,878 50, Childress 7,095 7,209 7 Clay 10,473 9,928 3 Cochran 3,016 2,805 0 Coke 3,210 2,998 1 Coleman 8,543 7,860 4 Collin 854,778 1,013,767 2,237 Collingsworth 3,099 3,186 1 Colorado 20,752 20, Comal 118, , Comanche 13,623 12,942 6 Concho 4,043 3,954 0 Cooke 38,467 38, Coryell 76,192 77, Cottle 1,452 1, P a g e

8 Crane 4,773 5,642 1 Crockett 3,807 3,990 0 Crosby 5,991 5,859 2 Culberson 2,277 2,049 1 Dallam 7,057 7,805 0 Dallas 2,480,331 2,718,443 5,924 Dawson 13,810 13,755 4 Deaf Smith 19,177 18,793 8 Delta 5,238 5,248 1 Denton 728, , DeWitt 20,503 21,323 8 Dickens 2,291 2,002 1 Dimmit 10,897 12,858 4 Donley 3,522 3,226 1 Duval 11,640 11,361 0 Eastland 18,245 17,588 6 Ector 149, , Edwards 1,884 1,662 0 El Paso 827, ,003 1,134 Ellis 155, , Erath 39,658 43, Falls 17,493 16,758 7 Fannin 33,659 33,120 8 Fayette 24,821 25, Fisher 3,856 3,625 2 Floyd 6,230 5,806 4 Foard 1,277 1,165 0 Fort Bend 652, ,714 1,412 Franklin 10,660 10,767 4 Freestone 19,646 19,332 8 Frio 18,065 19,835 4 Gaines 18,921 21,948 6 Galveston 306, , Garza 6,317 6,039 0 Gillespie 25,357 26, Glasscock 1,251 1,301 0 Goliad 7,465 7,988 1 Gonzales 20,312 21,328 6 Gray 23,043 24, Grayson 122, , Gregg 123, , Grimes 26,859 27,450 7 Guadalupe 143, , P a g e

9 Hale 35,764 34, Hall 3,239 3,019 1 Hamilton 8,310 7,911 8 Hansford 5,555 5,444 1 Hardeman 4,016 3,775 5 Hardin 55,417 56, Harris 4,336,853 4,857,275 9,605 Harrison 66,886 69, Hartley 6,100 6,173 5 Haskell 5,875 5,828 1 Hays 176, , Hemphill 4,158 4,923 4 Henderson 78,675 78, Hidalgo 815, , Hill 34,823 34, Hockley 23,530 24, Hood 52,905 56, Hopkins 35,565 36, Houston 22,911 21, Howard 36,147 38, Hudspeth 3,318 3,019 0 Hunt 87,048 88, Hutchinson 21,819 21,164 9 Irion 1,612 1,638 0 Jack 8,957 8,778 3 Jackson 14,591 15,671 2 Jasper 35,649 35, Jeff Davis 2,253 2,082 1 Jefferson 252, , Jim Hogg 5,245 5,140 0 Jim Wells 41,680 43, Johnson 154, , Jones 19,859 19,184 6 Karnes 15,081 15,594 5 Kaufman 108, , Kendall 37,766 47, Kenedy Kent Kerr 49,953 50, Kimble 4,481 4,239 2 King Kinney 3,586 3,564 0 Kleberg 32,101 32, P a g e

10 Knox 3,767 3,865 1 La Salle 7,369 8,401 1 Lamar 49,426 48, Lamb 13,775 13,389 4 Lampasas 20,222 21, Lavaca 19,581 20, Lee 16,628 16,661 6 Leon 16,742 16,608 3 Liberty 76,907 79, Limestone 23,326 23,186 9 Lipscomb 3,485 3,868 0 Live Oak 11,867 12,555 0 Llano 19,444 19, Loving Lubbock 289, , Lynn 5,723 5,357 4 Madison 13,781 14,001 2 Marion 10,235 9,641 1 Martin 5,312 6,449 1 Mason 4,128 4,367 1 Matagorda 36,592 36, Maverick 55,932 59, McCulloch 8,330 8,430 4 McLennan 241, , McMullen Medina 47,399 50, Menard 2,148 1,968 0 Midland 151, , Milam 24,167 23,007 4 Mills 4,907 4,848 0 Mitchell 9,402 9,400 2 Montague 19,503 19,074 7 Montgomery 499, , Moore 22,141 22, Morris 12,834 12,629 2 Motley 1,196 1,167 0 Nacogdoches 65,330 66, Navarro 48,038 48, Newton 14,140 13,546 1 Nolan 15,037 14,676 7 Nueces 352, , Ochiltree 10,806 12,038 3 Oldham 2,102 2, P a g e

11 Orange 82,957 85, Palo Pinto 27,889 27, Panola 23,870 24, Parker 121, , Parmer 9,965 9,367 3 Pecos 15,697 16,074 8 Polk 45,790 46, Potter 121, , Presidio 7,201 6,063 2 Rains 11,065 11,375 1 Randall 126, , Reagan 3,601 4,098 1 Real 3,350 3,430 0 Red River 12,470 11,697 3 Reeves 13,965 14,328 5 Refugio 7,305 7,144 1 Roberts Robertson 16,486 16,222 2 Rockwall 85, , Runnels 10,309 9,938 7 Rusk 53,622 54, Sabine 10,361 9,449 3 San Augustine 8,769 8,576 3 San Jacinto 26,856 27,823 3 San Patricio 66,137 68, San Saba 6,012 5,784 1 Schleicher 3,206 2,732 1 Scurry 17,302 18,098 5 Shackelford 3,375 3,368 0 Shelby 25,792 26,514 5 Sherman 3,093 3,211 0 Smith 216, , Somervell 8,658 9,004 9 Starr 61,963 63, Stephens 9,247 8,507 3 Sterling 1,219 1,380 0 Stonewall 1,432 1,320 1 Sutton 4,006 3,766 4 Swisher 7,763 7,577 2 Tarrant 1,911,541 2,125,634 3,205 Taylor 134, , Terrell Terry 12,743 12, P a g e

12 Throckmorton 1,600 1,520 2 Titus 32,581 33, Tom Green 114, , Travis 1,120,954 1,331,693 3,078 Trinity 14,393 14,019 2 Tyler 21,464 20,863 5 Upshur 39,884 41, Upton 3,372 3,406 1 Uvalde 26,926 28, Val Verde 48,623 48, Van Zandt 52,481 52, Victoria 90,028 96, Walker 68,817 70, Waller 45,213 49,373 4 Ward 11,244 12,481 1 Washington 34,147 35, Webb 262, , Wharton 41,216 41, Wheeler 5,751 6,476 0 Wichita 132, , Wilbarger 13,131 12,343 9 Willacy 21,921 21,483 7 Williamson 471, , Wilson 45,418 50, Winkler 7,606 8,671 1 Wise 60,939 64, Wood 42,306 42, Yoakum 8,184 8,822 2 Young 18,341 17, Zapata 14,390 15,167 5 Zavala 12,156 13,153 2 TOTALS 26,448,193 29,244,491 46,953 Source: American Medical Association Physician Master File/MMS/U.S. Census Bureau 2014 SEVERE SHORTAGE AREAS AND SPECIALTIES An examination of these numbers indicates that Texas, a large and demographically varied state, has a pronounced shortage of physicians in particular counties and in certain medical specialties, as well as fewer physicians per capita overall than the national average. Some counties have no physician of any kind, many have very few physicians, and an inordinate number have no physicians in certain key specialties. 10 P a g e

13 Counties Without a Physician: There are 35 counties in Texas without an active patient care physician. These counties include: Armstrong Concho Edwards Irion Kinney Menard Shackelford Borden Cottle Foard Jim Hogg Lipscomb Mills Sherman Brooks Crockett Garza Kenedy Live Oak Motley Sterling Carson Dallam Glasscock Kent Loving Real Terrell Cochran Duval Hudspeth King McMullen Roberts Wheeler Source: American Medical Association Physician Master File/MMS 2014 Below is a breakdown of the total population in these counties. Population of Texas Counties With No Physician Total Average High Low 115,826 3,309 11, It is to be expected that some counties in Texas will lack a physician, given that population levels in these counties may be too low to support a doctor. Below are suggested physician-to-population ratios as determined by Richard A. Cooper, M.D., a nationally known physician supply and utilization expert at the University of Pennsylvania/Wharton School and Director of the Center for the Future of the Healthcare Workforce at the New York Institute of Technology. These are demand-based ratios that suggest the number of physicians that can be economically supported by a given population. Calculated in 2013, they are the most recent such ratios of which Merritt Hawkins is aware; they are also the most real world ratios applicable, as they indicate not how many physicians a population may theoretically need, but how many it can sustain given economic and demographic considerations. Number of Physicians That Can be Supported per 100,000 Population Family Medicine 31.0 Internal Medicine 29.6 Pediatrics 16.1 Cardiology 7.1 General Surgery 10.7 Obstetrics/Gynecology 13.0 Orthopedic Surgery 7.9 Psychiatry 14.7 Population Needed to Support One Physician by Specialty Family Medicine 3,100 Internal Medicine 3, P a g e

14 Pediatrics 6,250 Cardiology 14,084 General Surgery 9,346 Obstetrics/Gynecology 7,692 Orthopedic Surgery 12,658 Psychiatry 6,802 Source: Richard A. Cooper, M.D./University of Pennsylvania/Wharton School As these numbers show, a county, community, or other medical service area requires slightly in excess of 3,000 people to support a single family physician or a general internist based on a national economic model. An analysis would need to be made of each county or service area to obtain a more exact number based on local economic, demographic and related conditions. However, 18 of 35 Texas counties with no physician currently have a population of 3,000 or more, and therefore may have the potential to support one or more primary care physicians. Counties With One to Five Physicians: There are 80 counties in Texas with one to five active patient care physicians. These counties include: 1 Briscoe 1 Rains 2 Trinity 4 Franklin 1 Coke 1 Reagan 2 Yoakum 4 Frio 1 Collingsworth 1 Refugio 2 Zavala 4 Hemphill 1 Crane 1 San Saba 3 Bailey 4 Lamb 1 Culberson 1 Schleicher 3 Baylor 4 Lynn 1 Delta 1 Stonewall 3 Castro 4 Mcculloch 1 Dickens 1 Upton 3 Clay 4 Milam 1 Donley 1 Ward 3 Jack 4 Sutton 1 Goliad 1 Winkler 3 Leon 4 Waller 1 Hall 2 Crosby 3 Ochiltree 5 Callahan 1 Hansford 2 Fisher 3 Parmer 5 Camp 1 Haskell 2 Jackson 3 Red River 5 Chambers 1 Jeff Davis 2 Kimble 3 Sabine 5 Hardeman 1 Knox 2 Madison 3 San Augustine 5 Hartley 1 La Salle 2 Mitchell 3 San Jacinto 5 Karnes 1 Marion 2 Morris 3 Stephens 5 Reeves 1 Martin 2 Presidio 4 Coleman 5 Scurry 1 Mason 2 Robertson 4 Dawson 5 Shelby 1 Newton 2 Swisher 4 Dimmit 5 Tyler 1 Oldham 2 Throckmorton 4 Floyd 5 Zapata Source: American Medical Association Physician Master File/MMS P a g e

15 Below is a breakdown of the population of these counties: Population of Texas Counties With One to Five Physicians Total Average High Low 782,790 9,785 45,213 1,432 Total Physicians Physicians per 100, These low-physician counties have a combined ratio of 26 physicians per 100,000 population compared to the national ratio of approximately 226 per 100,000 population and compared to the Texas ratio of approximately 183 per 100,000. Though these counties have at least one active patient care physician, as a group, and, most likely, individually, they can be considered severely underserved. Counties Without an Obstetrician There are 147 counties in Texas that do not have an active patient care obstetrician. These counties include: Aransas Clay Duval Haskell Lamb Mills San Augustine Tyler Archer Cochran Eastland Hemphill Lampasas Mitchell San Jacinto Upshur Armstrong Coke Edwards Houston Lavaca Montague San Patricio Upton Austin Coleman Fannin Hudspeth Lee Morris San Saba Uvalde Bailey Collingsworth Fisher Irion Leon Motley Schleicher Van Zandt Bandera Comanche Floyd Jack Limestone Ochiltree Scurry Waller Baylor Concho Foard Jackson Lipscomb Oldham Shackelford Ward Borden Coryell Franklin Jasper Live Oak Parmer Sherman Wheeler Bosque Cottle Freestone Jeff Davis Loving Pecos Somervell Wilbarger Brooks Crane Garza Jim Hogg Lynn Presidio Starr Willacy Burleson Crockett Glasscock Jones Madison Rains Stephens Wilson Caldwell Crosby Goliad Karnes Marion Reagan Sterling Winkler Callahan Culberson Gray Kenedy Martin Real Stonewall Wood Camp Dallam Grimes Kent Mason Red River Sutton Zavala Carson Deaf Smith Hall Kimble McCulloch Refugio Swisher Cass Delta Hamilton King McMullen Roberts Terrell Castro DeWitt Hansford Kinney Medina Robertson Terry Chambers Dickens Hardeman Knox Menard Runnels Throckmorton Childress Donley Hardin La Salle Milam Sabine Trinity Source: American Medical Association Physician Master File/MMS P a g e

16 Below is a breakdown of the population of these counties. Population of Texas Counties With No Active Patient Care Obstetrician Total Average High Low 1,940,722 13,202 76, The total population of counties in Texas without an obstetrician (1,904,722) is roughly equal to or larger than the population of 14 individual states, including Wyoming, Vermont, North Dakota, South Dakota, Alaska, Delaware, Montana, Rhode Island, New Hampshire, Maine, Hawaii, Idaho, Nebraska, West Virginia as well as the District of Columbia. Some of these counties do not have the population level necessary to support an obstetrical practice, about 7,700 people or above, per Dr. Cooper. However, 78 of the 147 Texas counties without an obstetrician currently do have a population of this size or greater and potentially could support one or more obstetricians. Texas Counties With No General Psychiatrist There are 185 counties in Texas with no general psychiatrist. These counties include: Andrews Childress Duval Hardin Kleberg Mitchell Runnels Upshur Aransas Clay Eastland Hartley Knox Montague Rusk Upton Armstrong Cochran Edwards Haskell La Salle Moore Sabine Uvalde Atascosa Coke Ellis Hemphill Lamb Morris San Augustine Waller Austin Coleman Fannin Hill Lee Motley San Jacinto Ward Bailey Collingsworth Fayette Hockley Leon Nacogdoches San Patricio Washington Baylor Colorado Fisher Hopkins Liberty Navarro San Saba Wharton Bee Comanche Floyd Houston Lipscomb Newton Schleicher Wheeler Blanco Concho Foard Hudspeth Live Oak Ochiltree Scurry Willacy Borden Cooke Franklin Hutchinson Llano Oldham Shackelford Wilson Bosque Coryell Freestone Irion Loving Orange Shelby Winkler Briscoe Cottle Frio Jack Lynn Palo Pinto Sherman Wise Brooks Crane Gaines Jackson Madison Panola Somervell Wood Brown Crockett Garza Jasper Marion Parmer Starr Yoakum Burleson Crosby Glasscock Jeff Davis Martin Pecos Stephens Young Burnet Culberson Goliad Jim Hogg Mason Presidio Sterling Zapata Caldwell Dallam Gonzales Jim Wells Matagorda Rains Stonewall Zavala Calhoun Dawson Gray Jones Maverick Reagan Sutton Callahan Deaf Smith Grimes Karnes McCulloch Real Swisher Camp Delta Hale Kenedy McMullen Red River Terrell Carson DeWitt Hall Kent Medina Reeves Terry Cass Dickens Hamilton Kimble Menard Refugio Throckmorton Castro Dimmit Hansford King Milam Roberts Trinity Chambers Donley Hardeman Kinney Mills Robertson Tyler Source: American Medical Association Physician Master File/MMS P a g e

17 Below is a breakout of the population of these counties. Population of Texas Counties With No General Psychiatrist Total Average High Low 3,274,774 17, , The combined population of Texas counties now without a general psychiatrist (3,274,774) is roughly equal to or larger than that of 21 individual states, including Wyoming, Vermont, North Dakota, Alaska, South Dakota, Delaware, Montana, Rhode Island, New Hampshire, Maine, Hawaii, Idaho, West Virginia, Nebraska, New Mexico, Nevada, Kansas, Utah, Arkansas, Mississippi, Iowa, as well as the District of Columbia. Texas has the fourth lowest number of psychiatrists per 100,000 population in the United States (4.1 per 100,000). Only Nevada, Mississippi, and Idaho have fewer psychiatrists per capita (Source: AMA Physician Master File). Again, some of these counties do not have the population level required to support a psychiatric practice (6,800 people or more). However, 122 of the 185 Texas counties without a general psychiatrist currently do have a population of this size or greater and potentially could support one or more general psychiatrists. Texas Counties With No General Surgeon There are 158 counties in Texas with no general surgeon. These include: Aransas Cass Delta Gonzales Kent Mason Real Stonewall Archer Castro Dewitt Grimes Kimble Mcculloch Red River Sutton Armstrong Chambers Dickens Hall King McMullen Reeves Swisher Austin Cherokee Dimmit Hamilton Kinney Medina Refugio Terrell Bailey Childress Donley Hansford Kleberg Menard Roberts Terry Bandera Clay Duval Hardeman Knox Milam Robertson Throckmorton Bastrop Cochran Eastland Hardin La Salle Mills Runnels Trinity Baylor Coke Edwards Hartley Lamb Mitchell Sabine Upton Blanco Coleman Falls Haskell Lampasas Montague San Augustine Van Zandt Borden Collingsworth Fannin Hemphill Lavaca Morris San Jacinto Waller Bosque Comanche Fisher Hill Lee Motley San Saba Ward Brewster Concho Floyd Hudspeth Leon Newton Schleicher Wheeler Briscoe Coryell Foard Hutchinson Limestone Ochiltree Scurry Willacy Brooks Cottle Franklin Irion Lipscomb Oldham Shackelford Wilson Burleson Crane Freestone Jack Live Oak Palo Pinto Shelby Winkler Caldwell Crockett Frio Jeff Davis Loving Parmer Sherman Yoakum Calhoun Crosby Gaines Jim Hogg Lynn Pecos Somervell Zapata Callahan Culberson Garza Jones Madison Presidio Starr Zavala Camp Dallam Glasscock Karnes Marion Rains Stephens Carson Dawson Goliad Kenedy Martin Reagan Sterling Source: American Medical Association Physician Master File/MMS P a g e

18 Below is a breakout of the population of these counties: Population of Texas Counties With No General Surgeon Total Average High Low 2,066,766 13,081 76, The total population of counties in Texas without a general surgeon (2,066,766) is roughly equal to or larger than the population of 14 individual states, including Wyoming, Vermont, North Dakota, South Dakota, Alaska, Delaware, Montana, Rhode Island, New Hampshire, Maine, Hawaii, Idaho, West Virginia and Nebraska, as well as the District of Columbia. Seventy-four of the Texas counties without a general surgeon currently have a population of approximately 9,400 people or more and therefore potentially could support one or more general surgeons. Effect on Rural Hospitals The presence of at least one primary care physician and one general surgeon in a service area supporting a hospital can be essential. The primary care physician is required to admit patients for inpatient and outpatient care while a general surgeon frequently is needed to perform the procedures that keep small (typically Critical Access) hospitals financially viable. Without these two key providers, hospitals may be forced to close. A report entitled The National Economic Impact of Physicians, prepared by IMS Health for the American Medical Association, quantifies the economic contributions of office based physicians (see chart below): Economic Impact of Physicians Total economic output: The combined economic output of patient care physicians in the United States is $1.6 trillion. Per capita economic output: Each physician supports a per capita economic output of $2.2 million. Jobs: On average, each physician supports 14 jobs. Wages and benefits: On average, each physician supports a total of $1.1 million in wages and benefits. Tax revenues: On average, each physician supports $90,449 in local and state tax revenues. Average Per Capita Economic Output of Patient Care Physicians in Texas Output (in billions) Output per Physician $78.6 $1,626,858 Source: The American Medical Association: The National Economic Impact of Physicians, prepared by IMS Health March 2014 There are 183 rural hospitals in Texas out of some 580 total licensed hospitals, with rural defined as a county population of 75,000 or less (Texas Organization of Rural and Community Hospitals). These hospitals provide access to routine care and emergency care to 15% of the state s population, but cover 16 P a g e

19 85% of the state s geography. Texas has 80 Critical Access Hospitals (CAHs) that have 25 or fewer beds and are at least 35 miles from anther hospital. Because hospitals often are the first or second largest employer in small communities, a domino effect takes place when a hospital closes due to lack of physicians. The local economy contracts and the community finds it difficult to attract new businesses to an area with no hospital. It often can be observed that as rural physicians go, so go rural communities. According to the National Rural Health Association, 48 rural hospitals have closed nationwide since 2010, ten of them in Texas (The Washington Post, March 15, 2015). LOW PHYSICIAN RATIOS AND MALDISTRIBUTION Some 26,620 physicians in Texas 254-county service area (57% of the workforce) practice in the five largest counties in Texas (Harris, Dallas, Tarrant, Bexar, Travis), though these counties are home to 11,667,289 people, or only 44% of the total population. Smaller Texas counties of 40,000 or less account for 2,264,257 people in Texas (8.6% of the total population) but only 1,170 physicians (2.5% of the total physician workforce). Physician maldistribution is endemic nationally as well, as some 20% of the U.S. population lives in rural areas while only 9% of physicians practice in these areas, according to the National Rural Health Association. This is an ongoing problem in Texas and throughout the country, and is not likely to abate soon, as few newly trained doctors entering the workforce indicate a preference for rural areas. According to Merritt Hawkins 2015 Survey of Final-Year Medical Residents, only 3% of physicians completing their training would prefer a community of 25,000 people or less (see chart below). In What Size Community Would You Prefer to Practice? 10,000 or less 1.2% 10,001 25, % 25,001 50, % 50, , % 100, , % 250, , % 500,001 1 million 22.8% Over 1 million 23.7% Source: Merritt Hawkins 2015 Survey of Final-Year Medical Residents While having many individual counties that are medically underserved, Texas overall has a ratio of approximately 183 active patient care physicians per 100,000 population, which is considerably lower than the national ratio of 226 physicians per 100,000 population. Texas ranks 41 st out of 50 states in physicians per population (see chart below): Physicians per 100,000 Population/Texas and U.S. Texas Texas Rank United States nd P a g e

20 Source: Association of American Medical Colleges 2013 State Physician Workforce Data Book Rural and Urban Access Issues Illustrating the dual nature of Texas physician workforce, the ratio of physicians-per-population is about the same or higher than the national average in four of Texas five most populous counties, with Bexar County an exception (see chart below). Physicians per 100,000 Population in the Five Most Populous Counties in Texas Harris County Dallas County Tarrant County Bexar County Travis County By contrast, in Texas counties of 40,000 people or fewer, there is an average of 52 physicians per 100,000 population, just 28% of the overall Texas average and 23% of the national average. However, even urban areas in Texas have generally fewer physicians per population than cities in other states that have large urban centers (see chart below). Active Physicians per 100,000 Population for Various Large Cities City or State Physicians per 100,000 Boston Massachusetts 324 Philadelphia Washington, D.C Seattle Portland New York 288 Maryland 285 Connecticut 281 Rhode Island 279 Denver San Diego Detroit Minneapolis Los Angeles Miami Houston Atlanta Dallas/Fort Worth Texas United States Source: American Medical Association Physician Master File 18 P a g e

21 Texas therefore must be considered a physician shortage state, though it includes four large counties in which physician-to-population ratios are at or above the national average. However, even within these counties, physician access issues exist. A 2013 study sponsored by Parkland Hospital and the Dallas County health department indicates physician-to-population ratios vary dramatically within Dallas County, with a preponderance of physicians located in more affluent areas of the county and few doctors located in less affluent areas (see chart below): Primary Care Physicians per 100,000 Population/Dallas County Stemmons Corridor 252 South Dallas 113 Northeast Dallas 104 North Dallas 101 Outer Northwest 71 Northwest Dallas 68 Southeast Dallas 54 Irving 42 Southwest Dallas 36 Cedar Hill 32 Desoto/Lancaster 26 Grand Prairie 24 Wilmer-Hutchins/Seagoville 5 Source: Horizons. The Dallas County Community Health Needs Assessment, Less affluent residents in these counties may have difficulty accessing a physician based on the location of physician offices, lack of transportation to these offices, inability to afford health insurance, or inability to afford co-pays and deductibles. Physician access in Texas is therefore not divided strictly between urban/suburban and rural areas, but is also a function of economic status. The chart below indicates the number of people by state who did not access a physician based on financial limitations in the prior 12 months. Residents Who Did Not See a Physician in Past 12 Months Due to Financial Constraints 1 Mississippi 21.7% 46 Iowa 10.5% 2 Arkansas 21.2% 47 Vermont 10.0% 3 Texas 20.9% 48 Hawaii 9.3% 4 Florida 20.8% 49 Massachusetts 9.2% 5 South Carolina 20.5% 50 North Dakota 8.1% Source: Kaiser State Health Facts, Kaiser Commission on Medicaid and the Uninsured analysis of the Centers for Disease Control and Prevention s BRFSS 2012 survey results. Texas has the third highest number of residents who are impeded from seeing a physician based on personal financial constraints. 19 P a g e

22 HEALTH PROFESSIONALS SHORTAGE AREAS (HPSAs) Physician access within individual states, counties and smaller service areas is tracked by the federal Health Resources and Services Administration (HRSA) though Health Professional Shortage Area (HPSA) designations. A whole county or smaller service area is designated as a primary care HPSA if it falls below a ratio of one primary care physician per 3,500 population, a mental health HPSA if it falls below one psychiatrist per 30,000 population, and a dental HPSA if it falls below one dentist per 5,000 population. Source: Bureau of Clinician Recruitment and Service, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services The chart below shows the total number of primary care, mental health and dentistry HPSAs in the U.S. and Texas and the number of health professionals required to remove the HPSA designations. Primary Care Health Professional Shortage Areas Total Primary Care HPSA Percent of Need Met Practitioners Needed to Remove Designations HPSA Designation United States 6, % 8,073 Texas % 514 Dental Care Health Professional Shortage Areas Total Dental Care HPSA Percent of Need Met Practitioners Needed to Remove Designations HPSA Designation United States 4, % 7,208 Texas % 349 Mental Health Care Health Professional Shortage Areas Total Mental Health Care HPSA Percent of Need Met Practitioners Needed to Remove Designations HPSA Designation United States 3, % 2,707 Texas % 193 *U.S. totals include data from the territories. Source: Bureau of Clinician Recruitment and Service, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, HRSA Data Warehouse: Designated Health Professional Shortage Areas Statistics, as of April 28, 2014 A complete list of the all the HPSA designated counties and service areas in Texas for primary care, mental health and dental health is included in Appendix A of this report. As the chart above indicates, it will require 514 additional primary care physicians practicing in the appropriate areas to remove all Texas primary care HPSAs, 193 additional psychiatrists to remove all Texas mental health HPSAs, and 349 additional dental professionals to remove all Texas dental health HPSAs. It should be noted that removing these designations would not necessarily provide the optimal number of physicians in current HPSA designated areas or ensure reasonable access to physician services. Determining the optimal number of physicians a given area needs is difficult as there is no set standard 20 P a g e

23 or metric for the ideal number of physicians needed to provide accessible, quality care to all population groups. Merritt Hawkins therefore prefers to follow Dr. Cooper s model of determining physician community requirements based on the number of physicians by specialty that similarly sized and economically comparable communities have historically been able to sustain. Given this model, the number of physicians required in Texas is considerably higher than the number needed to remove primary care and mental health HPSA designations. To achieve the national ratio of 226 physicians per 100,000 population now sustained by the overall population of the United States, Texas would need 12,819 additional physicians. It should be further noted that the Texas HPSA designated areas listed in Appendix A include many areas within the largest counties in Texas. Dallas County, for example, includes 15 healthcare facilities designated as HPSAs as well as population groups within West Dallas, Irving, South Dallas, Grand Prairie and other areas. The other largest counties include similarly designated facilities and areas. Nationally, 33% of HPSAs are in non-rural areas, indicating, as referenced above, that physician maldistribution is present in both rural and non-rural areas. The Texas Physician Education Loan Repayment Program The Physician Education and Loan Repayment Program (PELRP), administrated by the Texas Education Coordinating Board, is one avenue by which avenue by which physician supply in HPSAs may be increased. The PELRP provides up to $160,000 in education loan repayments to physicians over four years. For physicians with loan indebtedness of at least $160,000 or more, payments are structured as follows: First year: $25,000 Second year: $35,000 Third year: $45,000 Fourth year: $55,000 First preference is given to physicians practicing primary care in a Texas HPSA and second preference is given to physicians practice specialty care in a Texas HPSA. PELRP was substantially defunded by the Texas Legislature for a period of two years and was not accepting loan applications from physicians during that time. However, it now has funding for a twoyear period for approximately 200 loans based on the first and second year amounts cited above as is accepting applications. If PELRP continues to maintain funding it may prove to be one method of more evenly distributing physicians throughout the state of Texas and of attracting physicians from out of state. A GROWING SUPPLY OF PHYSICIANS Though Texas faces considerable physician supply and access challenges, a positive trend is that the physician workforce in Texas is growing and exceeding population growth, which is unusual by national standards. Between 1987 and 2007, the U.S. population grew by 24% but the number of U.S. trained 21 P a g e

24 Enrollments physicians added to the workforce grew by only 8% (New Medical Schools Open but Physician Shortages Persist. American Medical News. March 29, 2010) By contrast, total physician supply in Texas has grown from approximately 34,000 physicians in 2004 to 46,953 physicians in 2014, a growth rate of approximately 35% (see chart below). In the same period, the general population in Texas grew from 22,490,022 to 26,956,958, a growth rate of 20%. Total Physician Supply in Texas, (All years rounded except 2014) ,000 37,000 39,000 40,000 42,000 46,953 Source: Health Professions Resource Center, Department of State Health Services/Texas Medical Association Many physicians newly licensed in Texas have been attracted from out of the state. Three of four newly licensed physicians in Texas are graduates of medical schools located outside of the state (Report of Committee on Physician Distribution and Health Care Access, Texas Medical Association, June 2015). In 2003, Texas elected to put a cap of $250,000 on non-economic damages per medical malpractice defendant. Before the cap, the average medical malpractice award in Texas was $1.2 million it subsequently decreased to $880,000 (The Wall Street Journal, May 19, 2008). Partly as a result, numerous physicians from out of state flocked to Texas -- some 7,000 in the three years following passage of tort reform, swamping the state with requests for licenses. An expanding economy has also been a magnet drawing physicians to Texas. Nevertheless, physician shortages persist, and Texas is addressing this issue by growing the number of medical school graduates it produces. In 2006, the Association of American Medical Colleges (AAMC) called for a 30% increase in medical school enrollment nationally. Texas met that goal in 2011, well ahead of the AAMC s national target date of 2015, and the projected achievement date for the nation of 2017 (see chart below) Medical School Entering Class for Texas, , Year Source: Texas Higher Education Coordinating Board/Texas Medical Association P a g e

25 Following is a breakdown of physicians per county in Texas in 2004 and 2014, showing rate of growth or decline. Physician Population per County % Increase/Decrease County Physicians Physicians % increase/decrease Anderson % Andrews % Angelina % Aransas % Archer 7 7 0% Armstrong Atascosa % Austin % Bailey % Bandera % Bastrop % Baylor % Bee % Bell % Bexar 3,268 4,808 47% Blanco 6 6 0% Borden Bosque % Bowie % Brazoria % Brazos % Brewster % Briscoe % Brooks Brown % Burleson % Burnet % Caldwell % Calhoun % Callahan % Cameron % Camp % Carson Cass % Castro % Chambers % Cherokee % Childress 7 7 0% 23 P a g e

26 Clay 3 3 0% Cochran Coke 1 1 0% Coleman % Collin 1,466 2,237 53% Collingsworth % Colorado % Comal % Comanche 6 6 0% Concho Cooke % Coryell % Cottle Crane % Crockett Crosby 2 2 0% Culberson % Dallam Dallas 4,043 5,924 47% Dawson % De Witt % Deaf Smith % Delta 1 1 0% Denton % Dickens 1 1 0% Dimmit % Donley 1 1 0% Duval Eastland % Ector % Edwards El Paso 804 1,134 41% Ellis % Erath % Falls 7 7 0% Fannin % Fayette % Fisher % Floyd 4 4 0% Foard Fort Bend 838 1,412 68% Franklin 4 4 0% Freestone % 24 P a g e

27 Frio 4 4 0% Gaines % Galveston % Garza Gillespie % Glasscock Goliad % Gonzales % Gray % Grayson % Gregg % Grimes % Guadalupe % Hale % Hall 1 1 0% Hamilton % Hansford 1 1 0% Hardeman % Hardin % Harris 6,489 9,605 48% Harrison % Hartley % Haskell % Hays % Hemphill % Henderson % Hidalgo % Hill % Hockley % Hood % Hopkins % Houston % Howard % Hudspeth Hunt % Hutchinson % Irion Jack 3 3 0% Jackson % Jasper % Jeff Davis 1 1 0% Jefferson % Jim Hogg % 25 P a g e

28 Jim Wells % Johnson % Jones % Karnes % Kaufman % Kendall % Kenedy Kent % Kerr % Kimble % King Kinney Kleberg % Knox 1 1 0% La Salle 1 1 0% Lamar % Lamb % Lampasas % Lavaca % Lee % Leon % Liberty % Limestone % Lipscomb Live Oak % Llano % Loving Lubbock % Lynn % Madison 2 2 0% Marion 1 1 0% Martin 1 1 0% Mason 1 1 0% Matagorda % Maverick % McCulloch 4 4 0% McLennan % McMullen % Medina % Menard Midland % Milam % Mills % 26 P a g e

29 Mitchell 2 2 0% Montague 7 7 0% Montgomery % Moore % Morris 2 2 0% Motley Nacogdoches % Navarro % Newton % Nolan % Nueces % Ochiltree % Oldham 1 1 0% Orange % Palo Pinto % Panola % Parker % Parmer 3 3 0% Pecos % Polk % Potter % Presidio % Rains % Randall % Reagan 1 1 0% Real Red River 3 3 0% Reeves % Refugio % Roberts Robertson % Rockwall % Runnels % Rusk % Sabine 3 3 0% San Augustine 3 3 0% San Jacinto 3 3 0% San Patricio % San Saba % Schleicher 1 1 0% Scurry % Shackelford Shelby % 27 P a g e

30 Sherman Smith % Somervell % Starr % Stephens 3 3 0% Sterling Stonewall 1 1 0% Sutton 4 4 0% Swisher 2 2 0% Tarrant 2,425 3,205 32% Taylor % Terrell Terry % Throckmorton % Titus % Tom Green % Travis 2,233 3,078 38% Trinity 2 2 0% Tyler % Upshur % Upton 1 1 0% Uvalde % Val Verde % Van Zandt % Victoria % Walker % Waller % Ward 1 1 0% Washington % Webb % Wharton % Wheeler % Wichita % Wilbarger % Willacy % Williamson % Wilson % Winkler 1 1 0% Wise % Wood % Yoakum % Young % Zapata % 28 P a g e

31 Zavala % Texas Total 33,675 46,953 39% Source: American Medical Association Physician Master File/MMS 2014 From , 24 counties in Texas (the majority of them small and rural) experienced a decline in the number of physicians, while 71 experienced 25% or more growth in the number of physicians, further highlighting the have/have-not quality of physician supply in the state. Projected Physician Growth By 2019, the general population in Texas is projected to increase from 26,448,193 to 29,244,491, a growth rate of 11%. If the physician workforce in Texas continues to grow at the rate it has during the previous five years (17%), it will total approximately 54,935 physicians by At that point, the ratio of physicians in the state will increase from 183 per 100,000 population to 188 per 100,000 population, still trailing the current national average and the average in 40 states. THE STATE OF PRIMARY CARE Primary care services are perceived to be in the greatest demand nationally. In 2010, the Association of American Medical Colleges (AAMC) projected there would be 131,000 too few physicians by 2025, including 65,000 too few in primary care. In March, 2015 the AAMC revised this projection to a maximum shortage of 90,400 physicians by 2025, many of them (but not the majority) in primary care. Below is a list of physicians by specialty in Texas, including those in primary care (considered in this report to be general practice, family practice, internal medicine, and pediatrics) and those in other specialty areas. Texas Physicians by Specialty: PHYSICIAN SPECIALTY COUNT OF PHYSICIANS Abdominal Radiology 18 Abdominal Surgery 2 Addiction Medicine 4 Addiction Psychiatry 23 Adolescent Medicine-IM 1 Adolescent Medicine-Peds 38 Adult Cardiothoracic Anesthesiology 67 Advanced Heart Failure and Transplant Cardiology 3 Advanced Surgical Oncology 8 Aerospace Medicine 49 Allergy 7 Allergy & Immun/diag Lab 2 Allergy & Immunology 265 Anatomic Pathology 40 Anesthesiology 2, P a g e

32 Anesthesiology/pain Management 109 Blood Banking 49 Cardiothoracic Radiology 1 Cardiovascular Disease 1,027 Child Abuse Pediatrics 2 Child Neurology 97 Child Psychiatry 468 Clinical Genetics 3 Clinical Molecular Genetics 1 Clinical Neurophysiology 113 Clinical Pathology 15 Colon & Rectal Surgery 120 Congenital Cardiac Surgery (Thoracic Surgery) 6 Cosmetic Surgery 9 Craniofacial Surgery 7 Critical Care Anesthesiology 56 Critical Care Pediatric 158 Critical Care Medicine 95 Critical Care Surgery 101 Dermatologic Surgery 11 Dermatology 630 Dermatopathology 70 Developmental - Behavioral Pediatrics 15 Diabetes 2 Diagnostic Radiology 1,421 Emergency Medical Services 2 Emergency Medical Toxicology 20 Emergency Medicine 2,283 Emergency Medicine/Family Medicine 1 Emergency/sports Medicine 3 Endocrinology 324 Endovascular Surgical Neuroradiology 2 Endovascular Surgical Neuroradiology (Neurology) 1 Epilepsy 1 Facial Plastic Surgery 23 Family Medicine/Preventive Medicine 1 Family Prac/sports Medicine 115 Family Practice 6,228 Family Practice/geriatric Med 70 Female Pelvic Medicine & Reconstructive Surgery 2 Female Pelvic Medicine and Reconstructive Surgery 3 Forensic Pathology 53 Forensic Psychiatry P a g e

33 Gastroenterology 730 General Practice 139 General Preventive Medicine 112 General Surgery 1,437 Geriatric Psychiatry 68 Gynecological Oncology 24 Gynecology 58 Hand Surgery 68 Hand Surgery (Plastic Surgery) 13 Hand Surgery (Surgery) 7 Hand Surgery/orthopedic Surg 55 Head & Neck Surgery 10 Hematology 51 Hematology/oncology 425 Hematology/pathology 94 Hepatology 7 Hospice & Palliative Medicine 43 Hospice & Palliative Medicine (Family Medicine) 1 Hospice & Palliative Medicine (Internal Medicine) 2 Hospitalist 43 Im - Cardiac Electrophysiology 116 Immunology 5 Infectious Diseases 393 Internal Medicine 5,429 Internal Medicine - Emergency Medicine 4 Internal Medicine - Family Practice 2 Internal Medicine - Geriatrics 222 Internal Medicine - Neurology 1 Internal Medicine - Pediatrics 253 Internal Medicine - Preventive Medicine 8 Internal Medicine - Psychiatry 3 Internal Medicine - Sports Med 3 Interventional Cardiology 269 Legal Medicine 5 Maternal & Fetal Medicine 29 Medical Biochemical Genetics 2 Medical Genetics 46 Medical Management 4 Medical Microbiology 7 Molecular Genetic Pathology 16 Musculoskeletal Radiology 8 Neonatal-Perinatal Medicine 381 Nephrology P a g e

34 Neurodevelopmental Disabilities 7 Neurological Surgery 312 Neurology 658 Neuromuscular Medicine 13 Neuropathology 25 Neuropsychiatry 2 Neuroradiology 233 Nuclear Medicine 57 Nuclear Radiology 9 Nutrition 5 Obstetric Anesthesiology 2 Obstetrics 7 Obstetrics & Gynecology 2,598 Occupational Medicine 103 Oncology 332 Ophthalmic Plastic and Reconstructive Surgery 1 Ophthalmology 951 Ophthalmology/pediatrics 8 Oral And Maxillofacial Surgery 35 Orthopaedic Surgery Of Spine 67 Orthopedic Adult Recon Surgery 21 Orthopedic Musculo Oncology 8 Orthopedic Pediatric Surgery 47 Orthopedic Sports Medicine 124 Orthopedic Surgery 1,016 Orthopedic Surgery - Trauma 13 Orthopedics (foot & Ankle) 7 Osteopathic Manipulative Medicine 5 Other Specialty 66 Otolaryngology 553 Otology - Neurotology 8 Pain Management 49 Pain Medicine 152 Pain Medicine (Neurology) 1 Pain Medicine (Physical Med & Rehab) 4 Palliative Medicine 11 Pathology - Anatomic/clinical 732 Pathology - Chemical 2 Pathology - Cytopathology 96 Pediatric Allergy 3 Pediatric Anesthesiology 146 Pediatric Cardiology 166 Pediatric Cardiothoracic Surgery 5 32 P a g e

35 Pediatric Dermatology 2 Pediatric Emergency Medicine-EM 9 Pediatric Emergency Medicine-Peds 109 Pediatric Endocrinology 80 Pediatric Gastroenterology 81 Pediatric Hematology Oncology 189 Pediatric Infectious Diseases 60 Pediatric Nephrology 53 Pediatric Neurological Surgery 6 Pediatric Otolaryngology 26 Pediatric Pathology 32 Pediatric Pulmonology 68 Pediatric Radiology 75 Pediatric Rehab Medicine 5 Pediatric Rheumatology 18 Pediatric Sports Medicine 7 Pediatric Surgery 87 Pediatric Transplant Hepatology 2 Pediatric Urology 25 Pediatrics 3,500 Pediatrics - Emergency Medicine 3 Pediatrics - Medical Genetics 2 Pediatrics - Psychiatry 6 Pediatrics/Physical Medicine and Rehabilitation 1 Pharmacology - Clinical 2 Phlebology 8 Physical Medicine & Rehab 546 Plastic Surgery 470 Plastic Surgery - Head & Neck 1 Plastic Surgery Integrated 2 Procedural Dermatology 19 Psychiatry 1,464 Psychiatry - Family Practice 2 Psychiatry - Neurology 1 Psychoanalysis 5 Psychosomatic Medicine 7 Public Health/genl Prevent Med 24 Pulmonary Critical Care Med. 425 Pulmonary Disease 172 Radiation Oncology 274 Radiology 96 Reproductive Endocrinology 39 Rheumatology P a g e

36 Selective Pathology 102 Sleep Medicine 77 Sleep Medicine (Psych & Neurology) 2 Spinal Cord Injury 19 Sports Medicine (Physical Medicine & Rehab) 3 Surgical Oncology 22 Thoracic Surgery 233 Transitional Year 1 Transplant Hepatology (Internal Medicine) 15 Transplant Surgery 14 Traumatic Surgery 16 Undersea and Hyperbaric Medicine-EM 3 Undersea Medicine 11 Unspecified Specialty 78 Urgent Care Medicine 18 Urological Surgery 518 Vascular & Interventional Rad 204 Vascular Neurology 30 Vascular Surgery 160 Vascular Surgery- Integrated 1 TOTAL RECORDS 46,953 Primary Care 15,296 (67.5%) Specialists 31,657 (32.5%) Source: American Medical Association Physician Master File/ MMS 2014 The charts below indicate how the percent of primary care physicians in Texas service area differs from the national physician workforce. Primary Care Physicians (PCPs) vs. Specialists in Texas and the U.S. United States All Texas Counties 35% 32.5% 65% 66.5% PCPs Specialists PCPs Specialists 34 P a g e

37 Top 5 Metro Counties Bexar, Dallas, Harris, Tarrant, Travis Remaining Counties 72% 28% 61% 39% PCPs Specialists PCPs Specialists Source: SK&A, 2014 As the charts illustrate, 32.5% of physicians in Texas are in primary care, compared to 35% nationally, and only 28% of physicians in the top five metro counties in Texas are in primary care. Texas ranks 47 th in the nation in PCPs per 100,000 population, and is particularly top heavy in specialty care in urban areas. Active Primary Care Physicians per 100,000 Population by State 1 Vermont Idaho Massachusetts Texas Maine Nevada New Hampshire Utah Rhode Island Mississippi 58.8 Source: 2013 State Physician Workforce Data Book. Association of American Medical Colleges. Nationally, there are 80.7 PCPs per 100,000 population. In Texas, there are 63.3 PCPs per 100,000 population. Texas will be challenged in growing its own primary care physicians, as the state ranks 37 th in the country in percent of residents and fellows in primary care graduate medical education programs (see chart below): Primary Care Residents and Fellows per 100,000 Population 1 New York Mississippi Rhode Island Nevada Massachusetts Idaho Connecticut Alaska Pennsylvania Montana Texas 9.2 United States 13.6 Source: 2013 State Physician Workforce Data Book. Association of American Medical Colleges 35 P a g e

38 To maintain or increase PCP to population ratios in Texas, more PCPs will need to be trained in the state, and those practicing in other states will have to be recruited. A SHORTAGE OF SPECIALISTS Though Texas has relatively high ratio of specialists to primary care physicians, this is not to suggest that there is an adequate supply of medical specialists in the state. Texas ranks below U.S. averages for physicians per 100,000 population for 36 out of 40 major medical specialties, including 33 non-primary care specialties. The chart below shows some of the specialties in which Texas is deficient relative to national averages. Texas Ratio of Physicians per 100,000 pop. As a % of U.S. Ratio Family medicine 87.6% Internal medicine 75.1% Pediatrics 75.1% Emergency medicine 75.9% Pulmonary disease 73.8% Cardiovascular disease 76.0% Child and adolescent psychiatry 68.8% Psychiatry 58.2% Vascular medicine 43.0% Source: Report of Committee on Physician Distribution and Healthcare Access. Texas Medical Association, June 2014 The only four specialties out of 40 referenced in the Texas Medical Association report cited above in which Texas is above national per capita numbers are aerospace medicine, medical genetics, transplant surgery and colon and rectal surgery. In addition to having fewer specialists per capita than national averages, specialists are unevenly distributed in Texas. As outlined above, many Texas counties lack a single general surgeon, psychiatrist or obstetrician, though they may have the necessary population to sustain these and other specialty practices. Attrition among the ranks of specialists also will be a growing concern in Texas and nationally, as physicians in many specialty areas are older on average than physicians in primary care (see chart below): Physicians 55 and Older By Specialty Specialty 55 or older Pulmonology 73% Oncology 66% Psychiatry 60% Cardiology 54% Orthopedic surgery 52% 36 P a g e

39 Source: AMA Physician Master File, June 2014 Neurology 50% General surgery 48% Urology 48% Primary Care Internal Medicine 40% Family Practice 38% Pediatrics 38% In general, older patients have a more pronounced need for medical specialists than do younger patients, as specialists treat the diseases and other medical conditions associated with old age. The Texas population is relatively younger than the U.S. population, somewhat inhibiting the need for specialists; nevertheless it includes over 2.9 million people who are 65 years old or older, many of them concentrated in rural counties. PHYSICIAN RETENTION IN TEXAS On a positive note, Texas retains a relatively high number of the physicians it educates and trains. Texas ranks second in the nation in retaining medical school graduates, trailing only California, and ranks fifth in retention of physicians completing medical residency (see charts below): Physicians Retained From Undergraduate Medical Education 1 California 62.4% 2 Texas 59.4% 3 Arkansas 58.4% 4 Mississippi 54.4% 5 Hawaii 52.8% Physicians Retained From Graduate Medical Education 1 California 69.5% 2 Alaska 67.8% 3 Montana 63.3% 4 Florida 58.7% 5 Texas 57.9% Source: State Physician Workforce Data Book. Association of American Medical Colleges Though Texas ranks high in terms of retention of physicians educated and trained in the state, it should be considered that the ability of the physician graduate medical education system in Texas to train more physicians is limited. The State of Texas will spend $32.8 million to finance nearly 6,500 medical residency positions in , according to the Texas Higher Education Board, but it will be challenged to continue retaining these physicians, as the chart below illustrates. 37 P a g e

40 Medical School Graduates and Residency Positions/ Texas/2013 Entry level GME positions/allopathic 1,568 Entry level GME positions/osteopathic 43 Medical school graduates 1,587 Source: Association of American Medical Colleges/Texas Medical Association As the numbers above show, in 2013, there were only 24 more residency positions in Texas than there were medical school graduates. These residency positions can also be matched with medical graduates from medical schools in other states and with graduates of international medical schools. The Texas Higher Education Coordinating Board recommends a ratio of residency positions that is 10% higher than the number of medical school graduates in a given state, which would require the addition of 135 additional GME positions in Texas as of 2013 and 589 positions by (Report of Committee on Physician Distribution and Health Care Access. Texas Medical Association, June 2014) At present, three new medical schools are being added in Texas, including the University of Texas at Austin Dell School of Medicine and the South Texas School of Medicine in McAllen and Harlingen, which will admit a total of 100 new allopathic medical students in The University of the Incarnate Word in San Antonio, a new private medical school, will admit its first class of 150 osteopathic medical students, also in With projected expansion of medical schools planned by Texas Tech University and Texas A&M University, the combined increase to the class size for the state by 2018 will be 320 students. Texas will then have 12 medical schools (Report of Committee on Physician Distribution and Health Care Access. Texas Medical Association, June 2014). However, no corresponding increase in the number of residency programs is planned, and this will be a key challenge to maintaining adequate physician supply in the state. DIVERSITY CHALLENGES Health policy planners and the academic medical establishment are striving to achieve diversity in the physician workforce so that it more closely mirrors the ethnic composition of the general population. Following is a breakdown of the ethnic composition of the physician workforce in the U.S. and Texas, as well as a breakdown of the general population in the U.S. and in Texas. The Physician Workforce by Ethnic Composition/ U.S. and Texas United States Anglo Black Hispanic Asian* Other 77.9% 4.2% 4.6% 12.5% 0.8% Texas Anglo Black Hispanic Asian Other 72.9% 3.9% 8.7% 14.2% N/A 38 P a g e

41 Source: Health Professions Resource Center, Center for Health Statistics, Texas Department of State Health Services, 2012 *Principally Asian, also Pacific Islander, Native American General Population by Ethnic Composition/ U.S. and Texas United States Anglo Black Hispanic Other** Total Population 199,161,169 41,096,749 41,096,749 22,129, ,128,839 63% 13% 17% 7% 100% Texas Anglo Black Hispanic Other Total Population 11,624,881 3,114,187 10,740,456 1,682,418 27,1961,942 43% 11% 40% 6% 100% Source: Texas Department of State Health Services 2014 **Principally Asian, also Pacific Islander, Native American As these number indicate, the general population in Texas includes a considerably higher percent of Hispanics than the general U.S. population, slightly fewer blacks, and a slightly higher number of Asians. The physician workforce in Texas has approximately the same number of blacks as the national physician workforce and a somewhat higher number of Asians than the national physician workforce. However, the number of Hispanic physicians in Texas is about twice that of the national physician workforce, 8.7% in Texas compared to 4.6% nationally. Nevertheless, the number of Hispanic physicians in Texas is not representative of the Hispanic population in the state, nor is the number of black physicians in Texas representative of the black population. Both groups are significantly underrepresented. Asian physicians, by contrast, are overrepresented relative to the general population of Asians in Texas. As is the case with the physician workforce, ethnic diversity in Texas varies based on geographic location. Following is an ethnic breakdown of the four most populous Metropolitan Statistical Areas in Texas. Texas Most Populous MSAs by Ethnic Composition Dallas-Fort Worth-Arlington MSA Anglo Black Hispanic Other Total Population 3,301,969 1,035,759 2,055, ,837 6,971,597 47% 15% 29% 8% 100% 39 P a g e

42 Houston-The Woodlands-Sugar Land MSA Anglo Black Hispanic Other Total Population 2,378,560 1,075,378 2,433, ,537 6,473,316 37% 17% 38% 9% 100% Austin-Round Rock MSA Anglo Black Hispanic Other Total Population 1,017, , , ,569 1,932,430 53% 7% 33% 8% 100% San Antonio-New Braunfels MSA Anglo Black Hispanic Other Total Population 802, ,769 1,287,621 98,324 2,330,586 34% 6% 55% 4% 100% Total of Four MSAs Anglo Black Hispanic Other Total Population 7,501,222 2,384,782 6,413,658 1,408,267 17,707,929 42% 14% 36% 8% 100% Source: Texas Department of State Health Services 2014 The Dallas-Fort Worth-Arlington MSA, as defined by the Texas Department of State Health Services, has a population of 6,971,597, or 25.7% of Texas overall population, and includes a higher number of blacks than the Texas population (15% vs. 11%), though a lower number of Hispanics (29% vs. 40%), and a slightly higher number of Asians (8% vs. 6%). The Houston-The Woodlands-Sugar Land MSA has a population of 6,473,316, or 23.8% of Texas population, also with a higher percent of blacks than the Texas population (17% vs. 11%), a lower number of Hispanics (38% vs. 40%) and a higher number of Asians (9% vs. 6%). The Austin-Round Rock MSA has a population of 1,932,430, or 7.1% of Texas overall service population, with a lower number of blacks than the Texas population (7% vs. 11%), a lower number of Hispanics (33% vs. 40%), and a higher number of Asians (8% vs. 6%). Lastly, the San Antonio-New Braunfels MSA has a population of 2,330,586, or 8.6% of Texas overall service population, with a lower number of blacks than the Texas population (6% vs. 11%), a considerably higher number of Hispanics (55% vs. 40%), and a greater number of Asians (8% vs. 6%). Together these four MSAs have a population of 17,707,929, or 65.2% of the total population in Texas. Just under 4% of Texas physicians are black, while 14% of the population in the state s four most 40 P a g e

43 populous MSAs are black. 8.7% of Texas physicians are Hispanic, while 36% of the population in the state s four most populous MSAs are Hispanic. 14.2% of Texas physicians are Asian while 8% of the population in the state s four most populous MSAs are Asian. To achieve diversity, Texas will have to add considerably more black physicians, particularly to its largest MSAs, while Hispanic physicians will need to be added throughout the state as they are more highly represented outside the most populous MSAs than inside. There are approximately 3,800 Spanish speaking physicians in Texas, or about 8.1% of the total physician population (AMA Physician Master File). With Spanish-speaking residents representing a fast growing segment, more Spanish speaking doctors will be required to meet the needs of this culturally diverse population. A GROWING DEMAND FOR PHYSICIANS In addition to low physician-to-population ratios, a geographic maldistribution of physicians, physician retention challenges, and a need for greater diversity in the physician workforce, further challenges will have to be addressed to ensure an adequate number of physicians in Texas. One of these challenges is a rapidly growing demand for physician services in the state. Texas experienced a population growth of 8 million people from 1990 to 2010 and led the nation in population growth in both the 2000 and 2010 census. The population will grow by 5 million more people by 2020, according to the U.S. Census Bureau. In addition, there are over 2.9 million Texans who now are 65 years old or older and who are Medicare eligible, while 5.7 million baby boomers in the state started to become eligible for Medicare in Over 11% of the state s population is composed of people 65 or older who are Medicare eligible, compared to 14.1% of the U.S. population, so age-driven demand for doctors in Texas will be somewhat less of a factor than in states with an older population. However, population aging also is a regional issue within the state. In 23.5% of Texas 254 counties (the majority of them small and rural), 20% or more of the population is 65 years old or older (see the chart listing these counties on page 45). This will drive demand for physicians relatively higher in those areas of the state that already have the most pronounced physician shortages. As the chart below indicates, the Medicare eligible see a physician at a much higher rate than do younger people. Annual Visits to Physician Offices by Age (Excludes Emergency Department Visits) 66 years old or older years old years old years old years old years old 2.0 Average 3.4 Source: National Ambulatory Medical Care Survey/Centers for Disease Control 41 P a g e

44 At the other end of the spectrum, physician need in Texas also will be driven by its high birth rate. Texas has a birth rate of 15.4 per 1,000 population, the third highest in the country behind Alaska and Utah (U.S. Census Bureau). Disease Incidence and Demand for Doctors Like the general population of the U.S., the Texas population is facing a wide range of health challenges. Eleven percent of Texas adults have been diagnosed with diabetes, 66% have been diagnosed as overweight or obese, 38% have been diagnosed with high cholesterol, and 31% have been diagnosed with hypertension (see chart below). Diabetes and obesity are particularly prevalent in Texas. Diabetes Death Rate per 100,000 Percent of Adults Who Have Diabetes Cancer Incidence per 100,000 Cancer Death Rate per 100,000 Percent of Adults Who Have Hypertension Percent of Adults Who Have High Cholesterol Has Cardiovascular Disease Heart Disease Death Rate per 100,000 Adult Overweight/ Obesity Rate United States % % 39% 2% % Texas % % 38% 2% % Rank amongst all states including D.C. (51). All rankings based on the highest rate to lowest rate Source: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, Division of Vital Statistics, National Vital Statistics Report Volume 61, Number 4, Table 19, May 8, 2013 Continued high rates of disease, driven by obesity, diabetes, and hypertension, in particular, will accelerate the need for additional physicians in Texas. Impact of Insurance Enrollment on Physician Demand in Texas Demand for physician services is partly a function of the prevalence of health insurance coverage in a community or service area. As the Massachusetts Medical Society has indicated in several studies, Massachusetts has long physician appointment wait times (see Massachusetts Medical Society 2013 Patient Access to Care). Similarly, in its 2014 Survey of Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates, Merritt Hawkins found that Boston has the highest physician appointment wait times of 15 major metro areas (see chart on next page). This is largely due to the fact that Massachusetts, including Boston, has achieved the highest rate of insurance coverage of any state, driving up the demand for physician services. 42 P a g e

45 Cumulative Average Wait Time in Days for a Physician Appointment in Five Specialties (Family Practice, Dermatology, Obstetrics/Gynecology, Orthopedic Surgery, Cardiology) Metro Area Time to Appointment (Days) Dallas 10.2 Los Angeles 12.2 Miami 13.6 Houston 14.0 Atlanta 14.0 Seattle 16.0 San Diego 16.2 New York 16.8 Washington, D.C Detroit 17.8 Minneapolis 19.2 Portland 19.4 Philadelphia 20.6 Denver 23.6 Boston 45.4 Total Cumulative Average Source: Merritt Hawkins 2014 Survey of Physician Appointment Wait Times In contrast to Massachusetts, Texas ranks first in percent of population without health insurance (see chart below). Population without Health Insurance Coverage 1 Texas 22.1% 2 Nebraska 20.7% 3 Florida 20.0% 4 Georgia 18.8% 5 Alaska 18.5% United States 14.5% Texas Children 16.0% United States Children 9.0% Source: Health Insurance Coverage in the United States. U.S. Census Demand for doctors in Texas is relatively inhibited for this reason, which helps explain why physician appointment wait times listed above in Texas cities such as Dallas and Houston are comparatively short even though these cities have fewer physicians per capita than most others on the list. 43 P a g e

46 The chart below indicates health insurance coverage patterns in Texas. Health Insurance in Texas Employer 46% Other private 5% Medicaid 15% Medicare 12% Uninsured 22% Source: Health Insurance Coverage in the United States. U.S. Census ACA/State Exchanges The Affordable Care Act (ACA) has increased insurance coverage in Dallas County, with the number of uninsured patients believed to have dropped from 28% to 22% since the law went into effect (Poor Seek Care in Medical Deserts. Dallas Morning News, January 18, 2015). The ACA also has increased the ranks of the insured throughout other areas of Texas. Since the first open enrollment period, Texas enrollment through ACA established State Insurance Marketplaces/Exchanges grew to 733,757 between October 1, 2013 and April 19, 2014 (see chart below for enrollee characteristics). Source: Characteristics of Texas State Insurance Exchange Enrollees 55% female 45% male 38% under the age of 35 30% between the ages 18 and 34 67% selected a Silver plan 23% selected a Bronze plan 84% selected a plan with financial assistance The second open enrollment period began November 15, 2014, and thousands of additional Texans are likely to be enrolled by the end this enrollment period. Texas chose not to expand Medicaid through the ACA. Since the first ACA open enrollment period in October, 2013, 134,363 Texans have gained Medicaid or Children s Health Insurance Program (CHIP) coverage. If Texas had expanded Medicaid, an additional 1,208,000 uninsured people would be able to gain coverage (www.hhs.gov/healthcare.com). Though Texas chose not to expand Medicaid through the ACA, Medicaid patient access to physicians in Texas grew at least temporarily as a result of the ACA, according to a New England Journal of Medicine study. The ACA funded a Medicaid reimbursement raise to physicians beginning in 2013 and ending December 31, Under this raise, Medicaid paid the same rate to family physicians, internists and pediatricians as Medicare. The higher reimbursement was available in states that expanded Medicaid and in those that did not. 44 P a g e

47 The study found that the availability of primary care appointments for Medicaid patients increased by an average of 8% in the ten states included in the study, and by 10% in Texas. Because Texas Medicaid reimbursement rates are relatively low compared to other states, Texas physicians received a relatively high pay hike of approximately 66%. (Medicaid Pay Hike Opened Doors for Patients, Study Finds. Kaiser Health News. January 21, 2015). The pay raise was enough to persuade Texas doctors who see Medicaid patients to schedule a greater number of such patients. However, the study did not examine if the pay raise led more physicians in Texas and elsewhere to participate in the Medicaid program. Now that Medicaid rates have been reduced, it can be presumed that Medicaid patient accessibility to primary care physicians will decline. PHYSICIAN PRACTICE PATTERNS/EFFECT ON ACCESS The gross number of physicians practicing in a given service area is not the sole determinant of physician supply and physician access in that area. How physicians choose to practice the types of patients they see, the number of patients they see, the hours they work, and related factors also are important. Physician practice patterns that affect patient access are reviewed below, beginning with Medicare and Medicaid acceptance rates among Texas physicians. The charts below indicate the number of people in Texas by county eligible for Medicare or Medicaid, the Texas counties where the Medicare eligible population is at or exceeds 20%, and the Texas counties where the Medicaid eligible population is at or exceeds 20%. Eligible for Medicare/Medicaid by County in Texas County Population (2013) Age 65+ % Age 65+ Population Poverty % Poverty Population Anderson 57, % 7, % 11,761 Andrews 16, % 1, % 2,100 Angelina 87, % 12, % 16,876 Aransas 24, % 6, % 4,774 Archer 8, % 1, % 981 Armstrong 1, % % 216 Atascosa 47, % 6, % 7,723 Austin 28, % 4, % 2,914 Bailey 7, % 1, % 925 Bandera 20, % 4, % 3,152 Bastrop 75, % 10, % 12,511 Baylor 3, % % 557 Bee 32, % 3, % 7,281 Bell 326, % 31, % 50,007 Bexar 1,817, % 199, % 319,899 Blanco 10, % 2, % 997 Borden % % 6 Bosque 17, % 4, % 2,625 Bowie 93, % 14, % 18,417 Brazoria 330, % 35, % 36, P a g e

48 Brazos 203, % 16, % 60,543 Brewster 9, % 1, % 1,151 Briscoe 1, % % 286 Brooks 7, % 1, % 2,772 Brown 37, % 7, % 6,946 Burleson 17, % 3, % 2,575 Burnet 43, % 9, % 7,143 Caldwell 39, % 5, % 7,336 Calhoun 21, % 3, % 3,838 Callahan 13, % 2, % 2,056 Cameron 417, % 50, % 145,212 Camp 12, % 2, % 2,706 Carson 6, % 1, % 433 Cass 30, % 6, % 6,339 Castro 8, % 1, % 1,935 Chambers 36, % 3, % 3,571 Cherokee 50, % 8, % 12,465 Childress 7, % 1, % 1,128 Clay 10, % 2, % 1,079 Cochran 3, % % 455 Coke 3, % % 353 Coleman 8, % 1, % 2,358 Collin 854, % 79, % 66,673 Collingsworth 3, % % 632 Colorado 20, % 4, % 3,445 Comal 118, % 20, % 12,085 Comanche 13, % 3, % 3,596 Concho 4, % % 667 Cooke 38, % 6, % 5,693 Coryell 76, % 6, % 10,210 Cottle 1, % % 224 Crane 4, % % 659 Crockett 3, % % 636 Crosby 5, % 1, % 1,588 Culberson 2, % % 574 Dallam 7, % % 1,277 Dallas 2,480, % 235, % 473,743 Dawson 13, % 1, % 3,024 Deaf Smith 19, % 2, % 3,624 Delta 5, % 1, % 938 Denton 728, % 60, % 63,406 DeWitt 20, % 3, % 2,768 Dickens 2, % % P a g e

49 Dimmit 10, % 1, % 2,888 Donley 3, % % 588 Duval 11, % 1, % 2,293 Eastland 18, % 3, % 3,467 Ector 149, % 14, % 23,751 Edwards 1, % % 347 El Paso 827, % 90, % 192,858 Ellis 155, % 17, % 18,561 Erath 39, % 5, % 8,844 Falls 17, % 2, % 3,656 Fannin 33, % 6, % 5,789 Fayette 24, % 5, % 2,879 Fisher 3, % % 659 Floyd 6, % 1, % 1,265 Foard 1, % % 197 Fort Bend 652, % 58, % 58,060 Franklin 10, % 2, % 1,535 Freestone 19, % 3, % 3,065 Frio 18, % 2, % 4,336 Gaines 18, % 1, % 3,179 Galveston 306, % 38, % 40,802 Garza 6, % % 979 Gillespie 25, % 7, % 3,043 Glasscock 1, % % 53 Goliad 7, % 1, % 1,097 Gonzales 20, % 3, % 4,448 Gray 23, % 3, % 3,364 Grayson 122, % 20, % 19,209 Gregg 123, % 17, % 21,652 Grimes 26, % 4, % 5,130 Guadalupe 143, % 18, % 13,889 Hale 35, % 4, % 7,975 Hall 3, % % 771 Hamilton 8, % 2, % 1,047 Hansford 5, % % 944 Hardeman 4, % % 1,068 Hardin 55, % 8, % 6,040 Harris 4,336, % 390, % 802,318 Harrison 66, % 9, % 10,702 Hartley 6, % % 525 Haskell 5, % 1, % 1,110 Hays 176, % 16, % 29,924 Hemphill 4, % % P a g e

50 Henderson 78, % 16, % 14,870 Hidalgo 815, % 81, % 283,967 Hill 34, % 6, % 5,920 Hockley 23, % 3, % 3,177 Hood 52, % 12, % 6,402 Hopkins 35, % 5, % 6,864 Houston 22, % 4, % 4,513 Howard 36, % 4, % 5,530 Hudspeth 3, % % 1,463 Hunt 87, % 13, % 17,323 Hutchinson 21, % 3, % 3,447 Irion 1, % % 140 Jack 8, % 1, % 1,496 Jackson 14, % 2, % 1,853 Jasper 35, % 6, % 6,346 Jeff Davis 2, % % 167 Jefferson 252, % 33, % 52,995 Jim Hogg 5, % % 734 Jim Wells 41, % 5, % 9,045 Johnson 154, % 19, % 18,565 Jones 19, % 2, % 3,674 Karnes 15, % 2, % 3,514 Kaufman 108, % 12, % 14,440 Kendall 37, % 6, % 3,512 Kenedy % % 135 Kent % % 69 Kerr 49, % 13, % 7,443 Kimble 4, % 1, % 874 King % % 17 Kinney 3, % % 922 Kleberg 32, % 3, % 7,865 Knox 3, % % 784 La Salle 7, % % 1,599 Lamar 49, % 8, % 9,440 Lamb 13, % 2, % 3,044 Lampasas 20, % 3, % 3,418 Lavaca 19, % 4, % 1,625 Lee 16, % 2, % 2,062 Leon 16, % 3, % 2,963 Liberty 76, % 9, % 14,151 Limestone 23, % 4, % 5,015 Lipsomb 3, % % 380 Live Oak 11, % 2, % 2, P a g e

51 Llano 19, % 6, % 2,742 Loving % % 11 Lubbock 289, % 33, % 59,022 Lynn 5, % % 1,156 Madison 13, % 2, % 3,473 Marion 10, % 2, % 2,375 Martin 5, % % 839 Mason 4, % 1, % 561 Matagorda 36, % 5, % 7,721 Maverick 55, % 6, % 17,059 McCulloch 8, % 1, % 1,383 McLennan 241, % 31, % 53,126 McMullen % % 147 Medina 47, % 7, % 8,390 Menard 2, % % 505 Midland 151, % 15, % 15,753 Milam 24, % 4, % 4,640 Mills 4, % 1, % 643 Mitchell 9, % 1, % 1,100 Montague 19, % 4, % 3,042 Montgomery 499, % 58, % 61,893 Moore 22, % 2, % 3,410 Morris 12, % 2, % 2,644 Motley 1, % % 305 Nacogdoches 65, % 8, % 16,790 Navarro 48, % 7, % 10,136 Newton 14, % 2, % 2,277 Nolan 15, % 2, % 2,782 Nueces 352, % 45, % 64,788 Ochiltree 10, % 1, % 1,869 Oldham 2, % % 298 Orange 82, % 12, % 11,946 Palo Pinto 27, % 4, % 5,159 Panola 23, % 3, % 3,031 Parker 121, % 17, % 13,235 Parmer 9, % 1, % 2,123 Pecos 15, % 1, % 2,621 Polk 45, % 9, % 9,250 Potter 121, % 13, % 28,104 Presidio 7, % 1, % 1,786 Rains 11, % 2, % 1,505 Randall 126, % 16, % 13,027 Reagan 3, % % P a g e

52 Real 3, % % 677 Red River 12, % 2, % 2,008 Reeves 13, % 1, % 3,058 Refugio 7, % 1, % 1,183 Roberts % % 25 Robertson 16, % 2, % 3,413 Rockwall 85, % 9, % 5,029 Runnels 10, % 2, % 2,258 Rusk 53, % 8, % 9,545 Sabine 10, % 2, % 2,673 San Augustine 8, % 2, % 2,315 San Jacinto 26, % 5, % 5,398 San Patricio 66, % 9, % 11,243 San Saba 6, % 1, % 914 Schleicher 3, % % 731 Scurry 17, % 2, % 2,716 Shackelford 3, % % 543 Shelby 25, % 4, % 5,700 Sherman 3, % % 424 Smith 216, % 32, % 36,085 Somervell 8, % 1, % 805 Starr 61, % 6, % 24,289 Stephens 9, % 1, % 1,738 Sterling 1, % % 184 Stonewall 1, % % 238 Sutton 4, % % 292 Swisher 7, % 1, % 1,793 Tarrant 1,911, % 189, % 290,554 Taylor 134, % 18, % 23,336 Terrell % % 90 Terry 12, % 1, % 1,784 Throckmorton 1, % % 219 Titus 32, % 4, % 7,168 Tom Green 114, % 16, % 18,623 Travis 1,120, % 90, % 195,046 Trinity 14, % 3, % 2,317 Tyler 21, % 4, % 3,735 Upshur 39, % 6, % 6,302 Upton 3, % % 577 Uvalde 26, % 4, % 7,135 Val Verde 48, % 6, % 10,746 Van Zandt 52, % 10, % 8,607 Victoria 90, % 12, % 15, P a g e

53 Walker 68, % 7, % 17,892 Waller 45, % 5, % 9,223 Ward 11, % 1, % 2,294 Washington 34, % 6, % 5,088 Webb 262, % 22, % 82,423 Wharton 41, % 6, % 7,749 Wheeler 5, % % 822 Wichita 132, % 17, % 20,599 Wilbarger 13, % 2, % 2,718 Willacy 21, % 2, % 8,768 Williamson 471, % 48, % 32,971 Wilson 45, % 6, % 5,223 Winkler 7, % % 974 Wise 60, % 8, % 6,581 Wood 42, % 11, % 6,177 Yoakum 8, % % 958 Young 18, % 3, % 2,935 Zapata 14, % 1, % 4,993 Zavala 12, % 1, % 4,255 TOTAL 26,448, % 2,962, % 4,654,882 US TOTAL 316,128, % 44,574, % 48,683,841 Texas Counties with 20%+ Population Eligible for Medicare Texas Counties with 20%+ Population Eligible for Medicaid County Population Age 65+ % Age 65+ County Population Poverty % Poverty (2013) Population (2013) Population Llano 19, % 6,455 Hudspeth 3, % 1,463 Menard 2, % 629 Willacy 21, % 8,768 Sabine 10, % 2,974 Starr 61, % 24,289 Kent % 231 Brooks 7, % 2,772 Jeff Davis 2, % 642 Zavala 12, % 4,255 Gillespie 25, % 7,100 Cameron 417, % 145,212 Motley 1, % 332 Hidalgo 815, % 283,967 Real 3, % 928 Zapata 14, % 4,993 Mason 4, % 1,098 Kenedy % 135 Coke 3, % 847 Webb 262, % 82,423 Wood 42, % 11,169 Maverick 55, % 17,059 Aransas 24, % 6,406 Brazos 203, % 60,543 Kerr 49, % 13,138 Coleman 8, % 2,358 Kimble 4, % 1,165 Hardeman 4, % 1,068 Hamilton 8, % 2,127 Crosby 5, % 1,588 Throckmorton 1, % 405 Uvalde 26, % 7, P a g e

54 Foard 1, % 322 Dimmit 10, % 2,888 Baylor 3, % 904 San Augustine 8, % 2,315 Kinney 3, % 897 Comanche 13, % 3,596 Stonewall 1, % 357 Walker 68, % 17,892 Cottle 1, % 357 Sabine 10, % 2,673 Edwards 1, % 462 Kinney 3, % 922 San Augustine 8, % 2,148 Nacogdoches 65, % 16,790 Mills 4, % 1,197 Motley 1, % 305 Trinity 14, % 3,454 Culberson 2, % 574 Bandera 20, % 4,924 Madison 13, % 3,473 Briscoe 1, % 367 Presidio 7, % 1,786 Hood 52, % 12,486 Cherokee 50, % 12,465 Bosque 17, % 4,160 Kleberg 32, % 7,865 Fayette 24, % 5,783 Castro 8, % 1,935 Terrell % 210 Frio 18, % 4,336 Coleman 8, % 1,982 Hall 3, % 771 Fisher 3, % 895 Menard 2, % 505 Rains 11, % 2,556 Karnes 15, % 3,514 Hall 3, % 745 El Paso 827, % 192,858 Leon 16, % 3,834 Marion 10, % 2,375 Comanche 13, % 3,106 Swisher 7, % 1,793 Marion 10, % 2,334 Potter 121, % 28,104 McMullen % 173 Schleicher 3, % 731 Red River 12, % 2,818 Erath 39, % 8,844 Delta 5, % 1,142 Hale 35, % 7,975 Lavaca 19, % 4,269 Bee 32, % 7,281 Donley 3, % 764 Lamb 13, % 3,044 Haskell 5, % 1,269 Shelby 25, % 5,700 Blanco 10, % 2,295 Val Verde 48, % 10,746 McCulloch 8, % 1,783 McLennan 241, % 53,126 Borden % 135 Titus 32, % 7,168 San Saba 6, % 1,275 Runnels 10, % 2,258 Armstrong 1, % 411 Gonzales 20, % 4,448 Knox 3, % 795 Dawson 13, % 3,024 Cass 30, % 6,339 Reeves 13, % 3,058 Eastland 18, % 3,813 Camp 12, % 2,706 Montague 19, % 4,076 Jim Wells 41, % 9,045 Refugio 7, % 1,527 La Salle 7, % 1,599 Runnels 10, % 2,144 Limestone 23, % 5,015 Burnet 43, % 9,071 Parmer 9, % 2,123 Houston 22, % 4,720 Navarro 48, % 10,136 Henderson 78, % 16,128 Matagorda 36, % 7,721 Dickens 2, % 465 Jefferson 252, % 52, P a g e

55 Goliad 7, % 1,515 Cass 30, % 6,339 Morris 12, % 2,605 Falls 17, % 3,656 Tyler 21, % 4,357 Knox 3, % 784 Presidio 7, % 1,455 Robertson 16, % 3,413 Roberts % 168 Wilbarger 13, % 2,718 Colorado 20, % 4,171 Morris 12, % 2,644 Franklin 10, % 2,132 Collingsworth 3, % 632 Ward 11, % 2,294 TOTALS 823, % 190,940 Lubbock 289, % 59,022 Waller 45, % 9,223 Floyd 6, % 1,265 Anderson 57, % 11,761 Real 3, % 677 Polk 45, % 9,250 Lynn 5, % 1,156 San Jacinto 26, % 5,398 TOTALS 4,777, % 1,286,737 Source: United States Census Bureau, 2014 As these numbers show, 17.6% of Texas population is below the poverty level and may qualify for Medicaid, compared to 15.4% nationally. There are 78 counties in Texas where Medicaid eligible residents make up 20% or more of the population, and 11 counties where Medicaid eligible residents make up 30% or more of the population. The chart below indicates current Medicaid/CHIP enrollment in Texas and nationally. Source: Centers for Medicare & Medicaid Services, Medicaid.gov As referenced above, 11.2% of Texas population has reached the age of Medicare eligibility compared to 14.1% of the general population. There are 69 mostly rural Texas counties where Medicare eligible residents make up 20% or more of the population and one Texas County where Medicare eligible residents make up 30% or more of the population. 53 P a g e

56 Whether those eligible for these government health insurance programs in Texas have reasonable access to physicians is determined to a significant extent by the number of physicians who accept these forms of insurance. The charts below reflect these numbers. Physician Medicare and Medicaid Acceptance Rates in Texas All Texas Counties Medicare 20% Medicaid 6% Both 60% None 14% Top 5 Metro Counties Bexar, Dallas, Harris, Tarrant, Travis Medicare 21% Both 58% Medicaid 6% None 15% 54 P a g e

57 Remaining Counties Medicare 18% Medicaid 5% Both 63% None 14% Source: SK&A, 2014 As these numbers indicate, the rate of Medicaid acceptance by physicians in Texas is 66%; the rate in the top five most populous counties is slightly lower at 64%; and the rate for the remaining less populous counties is 68%, indicating the rate of Medicaid acceptance in rural counties in Texas is slightly higher than in metro counties. The number of Texas physicians who do not accept Medicaid (34%) is higher than the national average of 18%, as determined by the 2014 Survey of America s Physicians, which Merritt Hawkins conducted on behalf of The Physicians Foundation (www.physiciansfoundation.com). In this extensive survey, based on data provided by over 20,000 physicians it showed that 31% of Texas physicians indicated they do not accept Medicaid (margin of error +/-.78% based on analysis provided by survey research experts at the College of Business Administration, University of Tennessee), a number similar to the 34% of Texas physicians who do not accept Medicaid as tracked by the data company SK&A referenced above. The chart below shows where Texas ranks by physicians who do not accept Medicaid: Physicians Who Do Not Accept Medicaid by State 1 New Jersey 32.7% 26 South Carolina 12.6% 2 Texas 31.0% 27 Kentucky 12.4% 3 Florida 29.4% 28 New Mexico 12.3% 4 Louisiana 29.2% 29 Washington 12.0% 5 California 25.8% 30 North Carolina 11.4% 6 Hawaii 21.1% 31 New Hampshire 11.0% 7 Georgia 21.0% 32 Iowa 10.7% 55 P a g e

58 8 New York 20.9% 33 Delaware 10.5% 9 Alabama 19.6% 34 Ohio 10.1% 10 Maryland 19.3% 35 Indiana 10.0% 11 Illinois 19.0% 36 Utah 9.7% 12 West Virginia 18.8% 37 Nebraska 8.6% 13 Rhode Island 18.8% 38 Oregon 8.3% 14 Virginia 18.8% 39 Massachusetts 8.1% 15 Colorado 18.8% 40 Arkansas 7.7% 16 Nevada 17.7% 41 South Dakota 7.1% 17 Tennessee 16.2% 42 Maine 6.1% 18 Mississippi 15.3% 43 Minnesota 5.8% 19 Missouri 15.1% 44 North Dakota 5.0% 20 Connecticut 15.0% 45 Idaho 4.7% 21 Michigan 14.4% 46 Wisconsin 4.4% 22 Kansas 13.9% 47 Wyoming 2.9% 23 Pennsylvania 13.5% 48 Alaska 2.6% 24 Arizona 13.4% 49 Montana 2.0% 25 Oklahoma 13.1% 50 Vermont 0.0% Source: A Survey of America s Physicians/The Physicians Foundation/Merritt Hawkins, 2014 In an additional survey, Merritt Hawkins examined physician appointment wait times and Medicare and Medicaid acceptance rates among physicians in five specialties (including family medicine) in 15 large metro areas nationwide. Two of these metro areas (Dallas/Fort Worth and Houston) are in Texas. The chart below indicates that Medicaid acceptance rates by physicians are lower in Dallas/Fort Worth than in all other cities except Denver, while Medicaid acceptance rates in Houston fall at the median point. Rates of Medicaid Acceptance by Physicians in Metro Areas Metro Area Rate of Acceptance San Diego 86% Washington, D.C. 71% Philadelphia 67% Boston 65% Portland 60% Miami 56% Seattle 55% Houston 55% Los Angeles 53% Detroit 50% Atlanta 40% Minneapolis 35% New York 32% Dallas/Fort Worth 30% Denver 20% 56 P a g e

59 Source: Merritt Hawkins 2014 Survey of Patient Appointment Wait Times While Texas has a relatively high Medicaid eligible population, it also has a relatively high number of physicians who do not accept Medicaid. Low Medicaid acceptance rates may be driven by the fact that a relatively high number of Texas physicians remain in independent practice. Because Medicare and Medicaid reimbursement rates often are relatively low compared to commercial rates, private practice doctors often have to limit the number of these patients in order to keep their practices financially viable. According to the Center for Medicare and Medicaid Services (CMS) Office of the Actuary, Medicare payments are about 80% of private health insurance while Medicaid payments are about 58%. In addition, Medicaid reimbursement rates in Texas are the 11 th lowest in the nation (chart below): Medicaid Physician Reimbursement Rates as a Percent of the National Average for All Services (Lowest to Highest) 1 Rhode Island.58 2 Michigan.76 3 New Jersey.77 4 California.80 5 New York.87 6 Missouri.87 7 Indiana.87 8 Florida.89 9 New Hampshire Ohio Texas Montana Delaware Wyoming North Dakota * Alaska 2.42 *Data available for only 49 states. Source: Medicaid Physician Fee Index. Kaiser Family Foundation. This virtually assures that Medicaid patients in Texas will have a difficult time accessing a regular physician, and likely will rely heavily on hospital emergency departments, urgent care centers, and Federally Qualified Health Centers (FQHCs) for physician services. As stated above, should Texas rethink its position on expanding Medicaid eligibility, over 1.2 million people would qualify for coverage. However, given low rates of Medicaid acceptance among Texas physicians, it is likely that many of those newly insured through Medicaid expansion would not be able to obtain timely access to a doctor. 57 P a g e

60 Impact of FQHCs FQHCs provide a site of service for those without insurance and for the medically underserved. The ACA expanded funding for FQHCs whose mission is to provide affordable, quality care to traditionally underserved populations. There are 70 FQHCs in Texas employing 497 physicians (see list below): FQHCs in Texas Year Funded Federal Qualified Health Center Name City Pre 2002 Atascosa Health Center, Inc. Pleasanton Number of Physicians Employed/Affiliated Pre 2002 Brownsville Community Health Center Brownsville 13 Pre 2002 Central Care Community Health Center (South Central Houston Action Houston 1 Council) Pre 2002 Centro De Salud Familiar La Fe El Paso 4 Pre 2002 Centro San Vicente El Paso 8 Pre 2002 CentroMed (El Centro Del Barrio, Inc.) San Antonio 27 Pre 2002 Coastal Health and Wellness (Galveston County Coordinated Community La Marque 2 Clinics) Pre 2002 Communicare (Barrio Comprehensive Family Health Care Center, Inc.) San Antonio 20 Pre 2002 Community Health Care Center (North Central Texas Community Health Wichita Falls 6 Care) Pre 2002 Community Health Center of Lubbock Lubbock 10 Pre 2002 Community Health Centers of South Central Texas Inc. Gonzales N/A Pre 2002 Community Health Development, Inc. Uvalde 1 Pre 2002 Community Health Service Agency, Inc. Greenville N/A Pre 2002 CommUnityCare (Austin Travis County Health District) Austin 47 Pre 2002 Cross Timbers Health Clinic, Inc. De Leon 4 Pre 2002 Dallas County Hospital District Dallas 4 Pre 2002 East Texas Community Health Services Nacogdoches 4 Pre 2002 Gateway Community Health Center, Inc. Laredo 6 Pre 2002 Gulf Coast Health Center, Inc. Port Arthur 3 Pre 2002 Harris County Hospital District-- Healthcare For The Homeless Houston 10 Pre 2002 Healthcare For The Homeless--Houston Houston 10 Pre 2002 Heart of Texas Community Health Center, Inc. Waco N/A Pre 2002 La Esperanza Clinic, Inc. San Angelo N/A Pre 2002 Los Barrios Unidos Community Clinic Dallas 12 Pre 2002 Martin Luther King, Jr. Family Clinic, Inc. Dallas 7 Pre 2002 Nuestra Clinica Del Valle. Inc. Pharr 12 Pre 2002 Regence Health Network, Inc. Plainview N/A Pre 2002 South Plains Rural Health Services, Inc. Levelland 4 Pre 2002 South Texas Rural Health Services, Inc. Cotulla 1 Pre 2002 Su Clinica Familiar Harlingen N/A Pre 2002 United Medical Centers Eagle Pass 11 Pre 2002 Vida Y Salud Health Systems, Inc. Crystal City 1 58 P a g e

61 2002 Brazos Valley Community Action Agency, Inc. College Station Fort Bend Family Health Center, Inc. Richmond Cactus Health Centers Sanderson Community Action Corporation of South Texas Alice N/A 2003 El Centro de Corazon Houston Lone Star Community Health Center, Inc. Conroe Lone Star Circle of Care Georgetown Project Vida Health Center El Paso Good Neighbor Healthcare Center (Fourth Ward) Houston Midland Community Healthcare Services Midland North Texas Area Community Health Care (Fort Worth Northside Fort Worth 7 Community Health Center, Inc.) 2006 Pasadena Health Center Pasadena ResourceCare (Shackelford County Community Resource) Albany Spring Branch Community Health Center Houston Amistad Community Health Center Incorporated Corpus Christi Bayside Community Health Clinic (Chambers County Public Hospital Anahuac 4 District) 2007 Frontera Healthcare Network Eden Genesis Prime Community Health Care (East Texas Border Health Clinic) Marshall Health Center of Southeast Texas Cleveland Houston Community Health Centers, Inc. Houston Legacy Community Health Services, Inc. Houston Presidio County Health Services, Inc. Marfa N/A 2007 Wellness Point (Longview Wellness Center) Longview Health Opportunities for the People of East Texas, Inc. Center N/A 2009 Hope Clinic (Ellis County Coalition for Health Options) Waxahachie N/A 2009 Houston Area Community Services, Inc. Houston N/A 2009 Matagorda Episcopal Health Outreach Program Bay City Mt. Enterprise Community Health Center Mt. Enterprise Stephen F Austin Community Health Center, Inc. Alvin Texas Tech University Health Sciences Center, Larry Combest Center Lubbock Health Services of North Texas, Inc. Denton Hope Clinic (Asian American Health Coalition) Houston Mission East Dallas Dallas People's Community Health Clinic Austin Tejas Health Care La Grange Tyler Family Circle of Care Tyler Bee Busy Wellness Center Houston Saint Hope Foundation Houston 5 Source: Texas Department of State Health Services, P a g e

62 These facilities saw 1,727,000 individual patients in 2013, up from 1,085,199 in 2012, and handled 3,111,869 patient visits (National Association of Community Health Centers/Texas Health Center Fact Sheet). As the chart above indicates, 15 of these centers have been added since 2009 or later. The FQHC model is growing rapidly around the country, and given Texas high rate of uninsured and large number of underserved areas, the model appears particularly appropriate for the state. Impact of Urgent Care/Retail Urgent care centers are another delivery model that is proliferating across the nation and in Texas (see chart below). Source: Becker s Hospital Review. August, 2014 Growth in Urgent Care 9,300 urgent care centers in the U.S. 40% to expand to a new site 85% expect new patient growth 50% free standing 50% in retail shopping areas Currently, there are 706 urgent care centers in Texas. A list of Texas urgent care centers is included in Appendix B. These centers generally are staffed with physician assistants (PAs) and nurse practitioners (NPs) but may also have a physician (usually in primary care) on-site or supervising. Urgent care centers are increasing points of health care access, but not necessarily for those who do not have insurance or who are underserved. They principally provide convenient care to those who are insured but do not have timely access to a physician, and usually are located in urban/suburban retail areas. These centers represent a movement toward consumer driven care in which the larger entities that tend to own these centers can be everywhere, all the time. They feature the employed physician model and offer physicians set schedules, thereby likely reducing overall physician FTEs while at the same time increasing points of patient access (see below for a discussion of how physician employment is reducing FTEs). Urgent Care/ Retail Facilities in the Five Most Populous Counties in Texas Harris County Dallas County Tarrant County Bexar County Travis County As these numbers indicate, 57% of Texas urgent care centers are located in the five most populous counties in the state, which 44% of the population resides. Medicare Acceptance Given Medicare s relatively high reimbursement rate compared to Medicaid, the rate of Medicare acceptance by physicians in Texas is higher than the acceptance rate for Medicaid, as is to be expected. 60 P a g e

63 As the charts above show, the rate of Medicare acceptance in Texas is 80%, the rate in the top five most populous counties is 79%, and the rate in the remaining counties is 81%, indicating that the rate of Medicare acceptance is higher in rural counties than in metro counties. Of note is that fact that 14% of physicians in Texas do not accept Medicare nor do 15% of physicians in the top five most populous counties, and 14% of physicians in the remaining counties do not, according to SK&A data. As Richard Johnston, M.D. of USMD Holdings, Inc., a 350-physician group with offices throughout Dallas-Fort Worth calculates, independent primary care physicians can only afford to have 5%-10% of their practices composed of Medicare patients, after which the practice becomes fiscally unviable. In the 2014 Survey of America s Physicians referenced above, 18% of Texas physicians indicated they do not accept Medicare patients, a number somewhat larger than the 14% SK&A reports. The following chart shows where Texas physicians rank in Medicare acceptance rates relative to physicians in other states. Physicians Who Do Not Accept Medicare by State 1 Hawaii 19.1% 26 Illinois 12.3% 2 Texas 18.3% 27 Alabama 12.0% 3 West Virginia 17.9% 28 North Carolina 12.0% 4 Rhode Island 17.8% 29 Ohio 11.3% 5 Virginia 17.8% 30 Nebraska 11.2% 6 Iowa 17.8% 31 South Carolina 10.9% 7 Georgia 16.8% 32 Michigan 10.6% 8 Nevada 15.9% 33 Alaska 10.5% 9 Indiana 15.8% 34 Kentucky 10.4% 10 New Mexico 15.4% 35 Washington 10.1% 11 Florida 15.2% 36 Arizona 10.0% 12 California 15.1% 37 Delaware 9.6% 13 Tennessee 14.4% 38 Maine 9.2% 14 Maryland 14.2% 39 Pennsylvania 9.0% 15 Connecticut 13.8% 40 Missouri 8.9% 16 Louisiana 13.7% 41 Wyoming 8.8% 17 Colorado 13.4% 42 Minnesota 8.6% 18 New Jersey 13.1% 43 South Dakota 8.1% 19 Utah 13.0% 44 Vermont 7.4% 20 Mississippi 12.7% 45 Oregon 7.3% 21 Kansas 12.7% 46 Massachusetts 6.9% 22 New York 12.6% 47 Wisconsin 6.4% 23 Oklahoma 12.6% 48 Idaho 6.3% 24 New Hampshire 12.5% 49 Montana 6.0% 25 Arkansas 12.4% 50 North Dakota 5.0% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins, P a g e

64 The survey Merritt Hawkins conducted examining Medicare acceptance rates in 15 metro areas further indicates that Medicare acceptance rates by Texas physicians are relatively low. Medicare Acceptance Rates in 15 Major Metro Areas Metro Area Rate of Acceptance Boston 98.0 Detroit 95.8 Washington, D.C Los Angeles 86.3 Philadelphia 86.2 Portland 86.0 Seattle 85.7 Atlanta 82.0 Denver 74.4 Dallas 74.0 Houston 73.6 San Diego 70.2 Miami 68.7 New York 49.0 Minneapolis 38.2 Source: Survey of Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates/Merritt Hawkins, 2014 Though Texas has fewer Medicare eligible residents than the general population, somewhat inhibiting demand for physician services, it nevertheless has 5.7 million baby-boomers who began accessing Medicare in Given low Medicare acceptance rates and physician deficits in Texas, both in primary care and specialty care, Medicare eligible patients are likely to find it increasingly difficult to obtain timely access to physicians. State Exchange Participation Rates The state insurance exchanges established by the ACA have expanded the number of people in the U.S. who have health insurance. As of February 15, 2015, 9.1 million people nationwide are expected to have obtained health insurance through the exchanges (healthcare.gov). As with Medicare and Medicaid, the ability of these patients to see a physician will be determined to a large extent by the number of doctors participating in the exchanges. Based on the results of The Physicians Foundations survey cited above, 25.8% of Texas physicians participate in state insurance exchanges, compared to 33.3% of physicians nationwide. The chart below shows where Texas physicians rank in terms of participation in state exchanges: Physicians Participating in State Exchanges Established by the ACA by State 1 Vermont 62.5% 26 Georgia 32.8% 2 Idaho 55.6% 27 Maryland 31.9% 62 P a g e

65 3 Arkansas 54.9% 28 Illinois 31.7% 4 Washington 48.2% 29 New York 31.5% 5 Massachusetts 45.8% 30 Michigan 31.1% 6 Colorado 44.7% 31 Missouri 30.4% 7 Connecticut 44.2% 32 Delaware 30.3% 8 Nevada 43.9% 33 Ohio 29.3% 9 New Hampshire 43.0% 34 Kansas 29.1% 10 Oregon 42.8% 35 Pennsylvania 29.0% 11 Maine 42.4% 36 Utah 28.5% 12 Minnesota 42.2% 37 Rhode Island 28.1% 13 Arizona 39.8% 38 Virginia 28.1% 14 Montana 39.2% 39 West Virginia 28.1% 15 Wisconsin 38.8% 40 Hawaii 26.8% 16 Indiana 38.6% 41 North Carolina 26.6% 17 Wyoming 38.2% 42 South Dakota 26.2% 18 Kentucky 38.0% 43 Texas 25.8% 19 New Mexico 37.5% 44 Florida 25.5% 20 Nebraska 36.2% 45 Alabama 25.1% 21 South Carolina 36.2% 46 Mississippi 24.2% 22 California 36.0% 47 New Jersey 23.4% 23 Iowa 34.9% 48 North Dakota 22.6% 24 Tennessee 34.3% 49 Louisiana 22.4% 25 Alaska 34.2% 50 Oklahoma 20.6% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins, As the survey indicates, Texas ranks 43 rd in state exchange participation. 37.3% of Texas physicians indicated they have no plans to participate in the exchanges, while 10.8% said they do not participate but are likely to. The current low physician participation rate indicates those covered through the exchanges also may be challenged to find a regular physician. Overextended and Overworked The reasons why physicians may not be willing or able to accommodate those insured through Medicare, Medicaid and the state exchanges are not exclusively economic. In The Physicians Foundation survey referenced above, the majority of physicians nationally and in Texas indicated they now are overextended or are at full capacity. Nationally, 81% of physicians indicated they are now overextended or are at full capacity, while only 19% said they have the time to see more patients or take on new duties. The chart below indicates percent of physicians who are overextended or who are at full capacity by state. Physicians Who Are At Capacity or Overextended 1 Wyoming 97.1% 26 Delaware 80.2% 2 Vermont 87.2% 27 Utah 80.1% 3 Massachusetts 86.8% 28 Kentucky 79.9% 63 P a g e

66 4 Pennsylvania 86.2% 29 Mississippi 79.9% 5 Minnesota 85.7% 30 New York 79.4% 6 Ohio 85.4% 31 Nebraska 79.3% 7 Arkansas 85.0% 32 Rhode Island 79.3% 8 Washington 84.4% 33 Virginia 79.3% 9 Colorado 84.2% 34 West Virginia 79.3% 10 Connecticut 83.9% 35 Florida 79.1% 11 Michigan 83.3% 36 North Dakota 79.1% 12 Missouri 83.0% 37 Illinois 78.9% 13 North Carolina 83.0% 38 New Hampshire 78.9% 14 Nevada 82.6% 39 Texas 78.6% 15 Maryland 82.5% 40 South Carolina 78.5% 16 Montana 82.3% 41 Wisconsin 78.5% 17 Arizona 82.2% 42 Georgia 78.1% 18 Tennessee 82.1% 43 Indiana 77.8% 19 California 81.8% 44 Maine 77.6% 20 New Mexico 81.2% 45 Oklahoma 77.6% 21 Alaska 81.1% 46 Hawaii 77.0% 22 Oregon 81.1% 47 Kansas 76.0% 23 South Dakota 81.0% 48 Louisiana 73.5% 24 Iowa 80.7% 49 Alabama 73.4% 25 New Jersey 80.6% 50 Idaho 72.1% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins, 2014 Though Texas physicians are not at the top of this list, the great majority (78.6%) are overextended or are at full capacity, while only 21.4% have the time to see more patients or take on more duties. New responsibilities, such as implementation of ICD-10, are likely to consume additional physician time. When asked about ICD-10 implementation in The Physicians Foundation Survey, 58% of Texas physicians said it is likely to cause a severe administrative problem, compared to 50% of physicians nationally. Finding capacity in the current physician workforce will therefore be a challenge, and additional doctors will need to be trained in the state or recruited to Texas from other areas of the country to ensure timely access to physician services. Physician Practice Plans Medical practice in the United States traditionally has been characterized by full-time work in mostly clinical roles in an independent, privately owned setting. However, types of settings in which physicians choose to practice are changing. Doctors are no longer limited to working in solo or small, independent group practices. Today, they can be employed by a hospital, a large medical group, an urgent care center, FQHC, retail clinic, large employer, insurance company or a variety of other entities. 64 P a g e

67 Similarly, physicians no longer are limited to full-time, clinical private practice. Many physicians, dissatisfied with the current medical practice environment, are seeking alternatives to traditional practice styles. The Physicians Foundation survey referenced above asked physicians to indicate what they plan to do in the next one to three years. Results for all physicians and for Texas physicians are indicated below: In the Next One to Three Years, Do You Plan To: Texas All Continue as I am 52.1% 56.4% Cut back on hours 19.4% 18.2% Retire 11.7% 9.4% Switch to a cash/concierge practice 9.0% 6.2% Work locum tenens 9.3% 9.1% Cut back on patients seen 9.9% 7.8% Seek a non-clinical job within healthcare 11.0% 10.4% Seek employment with a hospital 6.9% 7.3% Work part-time 6.4% 6.4% Close my practice to new patients 3.3% 2.4% Other 6.9% 5.3% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins, 2014 While 52.1% of Texas physicians plan to continue their current style of practice, compared to 56.4% nationally, 47.9% plan to take one or a variety of steps likely to reduce patient access to their services. These steps include cutting back on hours, retiring, reducing the number of patients they see, working locum tenens, seeking a non-clinical job, working part-time or closing their practice to new patients. While it is difficult to quantify exactly how these changes will affect physician FTEs and patient access to medical services in Texas, some inferences can be made. Below is an examination of the potential impact on patient access to medical services should physicians in Texas choose to transition to concierge medicine. The Impact of Concierge Medicine It has been observed nationally and in Texas that some physicians are embracing concierge or direct pay medicine, a practice style in which physicians contract directly with patients, often in lieu of accepting government insurance plans such as Medicare and Medicaid and private insurance. In the 2014 Physicians Foundation survey, physicians were asked about their current position on concierge medicine (see chart below): What is Your Position on Concierge/Direct Pay Medicine? Texas All I now practice some form of concierge/direct pay medicine 9.3% 7.2% I am planning to transition fully or in part to this model 18.0% 13.3% I have no plans to transition to this model 72.7% 79.5% 65 P a g e

68 Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins The chart below indicates that a relatively high number of Texas physicians who now are practicing some form of concierge medicine or are planning to do so. Physicians Now Practicing Concierge Medicine or Planning To By State 1 Wyoming 38.2% 26 Kentucky 19.4% 2 Nevada 30.5% 27 Maryland 19.3% 3 Louisiana 28.8% 28 Iowa 19.2% 4 Florida 28.5% 29 Indiana 19.1% 5 Texas 27.3% 30 South Dakota 19.0% 6 Georgia 26.8% 31 Connecticut 18.9% 7 Mississippi 25.8% 32 New Hampshire 18.5% 8 Alaska 23.7% 33 Arkansas 18.0% 9 Utah 23.7% 34 Hawaii 18.0% 10 California 23.3% 35 Illinois 17.4% 11 Colorado 23.3% 36 South Carolina 17.2% 12 Oklahoma 23.2% 37 Minnesota 16.9% 13 Rhode Island 22.3% 38 Pennsylvania 16.2% 14 Tennessee 22.3% 39 Missouri 15.4% 15 Virginia 22.3% 40 Massachusetts 15.1% 16 West Virginia 22.3% 41 Alabama 15.0% 17 New York 22.1% 42 Washington 14.9% 18 New Mexico 21.9% 43 Maine 13.7% 19 Montana 21.6% 44 North Dakota 12.9% 20 North Carolina 21.1% 45 Idaho 12.7% 21 Kansas 20.9% 46 Oregon 11.0% 22 Michigan 20.6% 47 Wisconsin 10.9% 23 New Jersey 20.6% 48 Nebraska 9.4% 24 Ohio 20.5% 49 Delaware 9.2% 25 Arizona 19.4% 50 Vermont 4.2% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins The benefits and drawbacks of concierge medicine are the subject of continuing debate, with physicians in favor of the model arguing that it allows physicians to provide more personalized and effective care. Those opposed point out that primary care physicians converting to the concierge model often limit their practices to 500 to 600 patients, subsequently dropping three to four times that many patients from their practices. These patients then must find new physicians and may have difficulty doing so. As the numbers above indicate, the Texas service area may see a relatively high number of physicians embrace the concierge model, given the tradition of independent, private practice ownership in Texas, which is preserved in the concierge/direct pay style of practice. The concierge model also tends to proliferate in areas such as Dallas/Fort Worth, Austin, Houston, and San Antonio, which have a high 66 P a g e

69 concentration of patients who are both employed and have disposable income to invest in a more personalized style of care. The following chart tracks potential patients who may be compelled to find a new family physician depending on the number of physicians in Texas who convert to concierge practice in the future. It assumes 6,228 family physicians in Texas with an average patient panel of 3,000, for a total patient panel of 18,648,000. It further assumes that Texas physicians transitioning to the concierge model will drop an average of 2,500 of their current patients from their practices. Potential Number of Patients Requiring New Family Practice Physicians In Response to Physician Adoption of the Concierge Model in Texas Total Family Physicians in Texas: 6,228 Average patient panel: 3,000 (if consistent with national averages) Convert to Concierge Number of Patients Drop Number of Patients Requiring New Family Physician 5% 2, ,500 10% 2,500 1,557,000 15% 2,500 2,335,500 20% 2,500 3,114,000 These numbers are, of course, hypothetical, and the percent of Texas physicians who will eventually convert to concierge medicine is not known, nor is the average patient panel of each family physician in Texas. Nevertheless, it is clear that even if a modest number of Texas family physicians convert to concierge practice in coming years (considerably fewer than indicate they will do so in The Physicians Foundation survey), tens of thousands and perhaps hundreds of thousands of patients will need to find a new family physician. Part-time and Non-Clinical Practice Similar estimates could be made for physicians who indicated they will make other practice changes. For example, if 6.4% of Texas physicians choose to work part-time in the next one to three years, per The Physicians Foundation survey, it would equate to a loss of 1,500 physician FTEs. If 11% of Texas physicians obtain a non-clinical job in the next one to three years, per The Physicians Foundation Survey, it would equate to a loss of 5,164 physician FTEs from clinical roles. Again, it is not known how many physicians will actually pursue these options, but it is clear that changing practice patterns will have a significant, inhibiting effect on total physician FTEs in Texas and nationally, as more doctors migrate away from traditional, full-time, clinical private practice and toward part-time, non-clinical, concierge and other emerging practice models. Changing Physician Work Schedules Reduction in Texas physician FTE counts also may be driven by changing physician work schedules. With the advent of physician employment and younger physicians valuing a controllable lifestyle, physician productivity can be expected to decline. The survey Merritt Hawkins conducted for The 67 P a g e

70 Physicians Foundation referenced above illustrates that hours worked and patients seen by physicians have decreased in the last six years. Average Hours Worked by Physicians per Week Year Hours Decline of 5.9%/ Average Patients Seen per Day Year Patients Decline of 16.8%/ Source: A Survey of America s Physicians: The Physicians Foundation/Merritt Hawkins Assuming another 5.9% drop in average hours worked per week by physicians over the next six years, Texas current 46,953 physicians will represent only 43,823 FTEs in 2021, a loss of 2,770 FTEs by today s standards. Assuming a smaller, 3% drop in average hours worked over the next six years equates to a loss of 1,385 FTEs by Assuming another 16.8% drop in average number of patients seen per day over the next six years for Texas 6,228 family physicians equates to a reduction of 3,132,864 patients seen per year by Assuming a smaller, 8.4% reduction in patients seen by family physicians over the next six years equates to 1,566,432 fewer patients seen. Again, the exact percent of reduction in physician productivity cannot be predicted, but given that the trend toward employment and away from private practice still is accelerating, some drop can be predicted, and this will have a measurable effect on physician FTEs and patient access to physician services in Texas. IMPACT OF PHYSICIAN AGE In the next ten years, an aging physician population will have a profound impact on the physician workforce. Over 42% of all physicians in active patient care in the United States are 55 years old or older. In ten years, many of these physicians will be retired, and for the first time in the modern era of medicine there will likely be fewer physicians entering the workforce each year than exiting it. 68 P a g e

71 Data show that while the physician workforce in Texas will be significantly affected by physician aging, the impact could be relatively mitigated as Texas physicians are comparatively youthful compared to national averages (see charts below). United States (Age55+) All Texas Counties (Age 55+) 58% 42% 61% 39% Physicians 55+ Physicians 54 Physicians 55+ Physicians 54 Top 5 Metro Counties (Age 55+) Bexar, Dallas, Harris, Tarrant, Travis Remaining Counties (Age 55+) 62% 38% 60% 40% Physicians 55+ Physicians 54 Physicians 55+ Physicians P a g e

72 Unites States (Age 60+) All Texas Counties (Age 60+) 28% 24% 72% 76% Physicians 60+ Physicians 59 Physicians 60+ Physicians 59 Top 5 Metro Counties Bexar, Dallas, Harris, Tarrant, Travis Remaining Counties 24% 25% 76% 75% Physicians 60+ Physicians 59 Physicians 60+ Physicians 59 Source: SK&A, 2014 As these numbers indicate, only 39% of physicians in Texas are 55 years old and older, compared to 42% nationally, and 24% are 60 and older, compared to 28% nationally. Nevertheless, 39% of the total represents 18,311 physicians in Texas who are 55 or older, many of whom are likely to retire sometime in the next ten years. As stated above, physician practice patterns also must be taken into consideration. As noted in The Physicians Foundation survey, 45.4% of Texas physicians said they would accelerate their retirement plans given the changes taking place in medicine, compared to 38.6% of all physicians (see chart on following page). 70 P a g e

73 Physicians Planning to Accelerate Their Retirement Plans by State 1 Montana 62.2% 26 Maine 38.7% 2 Wyoming 55.9% 27 Iowa 38.6% 3 North Dakota 49.2% 28 Tennessee 38.4% 4 Oregon 48.3% 29 Missouri 38.3% 5 Arkansas 46.2% 30 Colorado 38.2% 6 Texas 45.4% 31 Illinois 38.2% 7 Louisiana 43.1% 32 Wisconsin 38.1% 8 South Carolina 43.1% 33 Washington 38.0% 9 Alabama 42.8% 34 Florida 37.9% 10 Mississippi 42.5% 35 Rhode Island 37.0% 11 North Carolina 42.2% 36 Virginia 37.0% 12 Ohio 42.2% 37 West Virginia 37.0% 13 Indiana 41.7% 38 Pennsylvania 36.7% 14 Utah 41.7% 39 New Jersey 36.5% 15 Kansas 40.9% 40 California 36.1% 16 Minnesota 40.9% 41 Vermont 35.4% 17 New Mexico 40.6% 42 Nevada 35.0% 18 Michigan 40.1% 43 Maryland 34.8% 19 Arizona 39.7% 44 New York 34.0% 20 Idaho 39.7% 45 Nebraska 33.9% 21 Oklahoma 39.6% 46 New Hampshire 33.9% 22 Georgia 39.4% 47 Delaware 32.9% 23 Kentucky 39.3% 48 Alaska 32.4% 24 Hawaii 38.9% 49 South Dakota 31.0% 25 Connecticut 38.7% 50 Massachusetts 29.1% Source: A Survey of America s Physicians: The Physicians Foundation/Merritt Hawkins Close to 12% of Texas physicians said they plan to retire in the next one to three years, compared to 9.4% of all physicians (see chart below). Physicians Who Plan To Retire In the Next 1-3 Years by State 1 Idaho 21.3% 26 Tennessee 8.4% 2 Montana 19.2% 27 Georgia 8.2% 3 New Mexico 18.2% 28 South Carolina 8.1% 4 Hawaii 17.6% 29 Missouri 7.9% 5 Maine 14.1% 30 New York 7.9% 6 Oregon 13.7% 31 Pennsylvania 7.9% 7 New Jersey 12.2% 32 Nevada 7.8% 8 Kansas 12.0% 33 New Hampshire 7.8% 9 Illinois 11.9% 34 North Carolina 7.8% 71 P a g e

74 10 Texas 11.7% 35 Oklahoma 7.8% 11 Washington 11.6% 36 Florida 7.6% 12 Alaska 11.1% 37 Wisconsin 7.5% 13 Minnesota 11.1% 38 Alabama 7.3% 14 Arkansas 11.0% 39 Kentucky 7.3% 15 Louisiana 10.9% 40 Michigan 7.2% 16 Mississippi 10.8% 41 Indiana 6.9% 17 Vermont 10.4% 42 Delaware 6.8% 18 Connecticut 10.0% 43 Iowa 6.5% 19 North Dakota 9.7% 44 Rhode Island 6.3% 20 California 9.4% 45 Virginia 6.3% 21 Ohio 9.0% 46 West Virginia 6.3% 22 Maryland 8.8% 47 Colorado 5.8% 23 Wyoming 8.8% 48 Massachusetts 5.4% 24 Nebraska 8.6% 49 South Dakota 4.8% 25 Arizona 8.5% 50 Utah 4.6% Source: A Survey of America s Physicians: The Physicians Foundation/Merritt Hawkins PHYSICIAN MORALE IN TEXAS The high rate of intended retirement among Texas physicians is in part a function of their professional morale, which is low compared to physicians in other states. The chart below indicates that morale among Texas physicians is lower than that of doctors in almost every other state. Physician Morale by State/ Percent Who Rate Morale as Positive 1 North Dakota 58.1% 26 New York 44.3% 2 Minnesota 54.8% 27 Illinois 44.1% 3 Rhode Island 52.9% 28 Wyoming 44.1% 4 Virginia 52.9% 29 Pennsylvania 44.0% 5 West Virginia 52.9% 30 Alabama 43.9% 6 Maryland 51.3% 31 Michigan 43.6% 7 Massachusetts 51.0% 32 Oregon 43.0% 8 Wisconsin 50.4% 33 Tennessee 43.0% 9 Iowa 49.7% 34 South Dakota 42.8% 10 Idaho 49.2% 35 Ohio 42.7% 11 Utah 48.5% 36 New Hampshire 42.6% 12 California 48.0% 37 Colorado 42.3% 13 Kansas 48.0% 38 New Jersey 42.3% 14 Vermont 47.9% 39 New Mexico 41.3% 15 Kentucky 47.7% 40 Connecticut 41.1% 16 Nebraska 47.5% 41 Georgia 41.1% 17 Alaska 47.4% 42 Florida 40.9% 18 Oklahoma 46.1% 43 Arizona 39.8% 72 P a g e

75 19 South Carolina 45.8% 44 Mississippi 39.8% 20 Washington 45.7% 45 North Carolina 38.8% 21 Delaware 45.3% 46 Texas 36.3% 22 Indiana 44.9% 47 Louisiana 35.7% 23 Missouri 44.9% 48 Nevada 32.8% 24 Hawaii 44.8% 49 Arkansas 32.4% 25 Maine 44.5% 50 Montana 29.4% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins One explanation for this is that many Texas doctors remain in private practice, and it is private practice physicians who feel the most alienated from today s medical practice environment. Rising costs, declining reimbursement, increased paperwork, additional regulatory oversight, and the stresses of running a business fall harder on independent doctors than they do on employed physicians. The chart below indicates the connection between private, independent practice and low physician morale. Physician Morale by Practice Status Very/Somewhat Positive Very/Somewhat Negative Employed 50.5% 49.5% Private/Independent 33.1% 66.9% Physicians with low professional morale are more likely to make changes in their practices than are those with high morale, including retirement, working part-time, reducing number of patients seen, and transitioning to concierge medicine. It therefore can be expected that a significant number of Texas physicians, whose morale is comparatively low, will seek and embrace alternate practice styles, reducing net physician FTEs. Employment and Productivity It is likely that the corporate practice of medicine law in Texas, which limits the number of entities that can employ physicians, has contributed to the high number of Texas physicians who have remained independent. However, the parameters of the law have broadened recently, allowing Texas physicians to have more latitude to seek employment with hospitals, and to also be employed by medical groups and other physician owned entities. As more Texas physicians become employed, overall physician productivity can be expected to decrease. According The Physicians Foundation s 2014 Survey of America s Physicians, independent, private practice physicians see 8.5% more patients per day than do employed physicians. THE IMPACT OF GENDER Approximately one-third (33%) of physicians in the United States are female, up from just 12% in 1981, according to Medical Marketing Systems (MMS). The number of female physicians has increased by 400% since 1981, while male physician ranks have increased by only 52%. The overall physician population has increased 35% since P a g e

76 Following is a breakout of the percent of physicians who are female nationally and in Texas. Percent of Physicians Who Are Female United States 33% Texas 31% Rank 26 th Source: American Medical Association Physician Master File Females compose a slightly smaller percentage of the workforce compared to the national physician workforce, ranking 26 th among states in this regard. However, the number of female physicians in Texas is growing rapidly, as it is nationwide. The number of female Texas physicians almost doubled in the last ten years, growing from 8,626 in 2003 to 16,804 in 2013, a 94.8% growth rate. (Report of Committee on Physician Distribution and Healthcare Access, Texas Medical Association). The number of female physicians in Texas grew three times faster than the number of male physicians in that time frame. Growth in the number of female physicians represents social progress, but also has significant workforce implications. Female physicians work approximately 8% fewer hours than do male physicians, according to The Physicians Foundation s 2014 Survey of America s Physicians, and see 13.3% fewer patients per day (see charts below). As the number of female doctors grows, both nationally and in Texas, overall physician productivity and FTE count can be expected to decline. Hours Worked Per Week Male and Female Physicians Male Female Patients Seen Per Day/Male and Female Physicians Male Female Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins Over half of students entering medical school today are female, and if current trends persist, half of physicians will be female, leading to a loss of thousands of physician FTEs. If today half of Texas 46,953 physicians were female, rather than 31%, some 713 FTEs would be lost, given an 8% reduction in productivity. TEAM-BASED MODELS, PAs AND NPs Healthcare is embracing a team-based delivery model in which patient care duties will be more appropriately distributed to a wider range of health professionals, including advanced practitioners such as physician assistants (PAs) and nurse practitioners (NPs). In the medical home model, primary care physicians will be the quarterbacks of the team, ensuring work is allocated appropriately among PAs, NPs, pharmacists, nurses, therapists, case managers, specialty physicians and others. Through more 74 P a g e

77 appropriate work allocation, and with each provider practicing to the top of his or her training, some practice efficiencies may be gained and physician time and access increased. There currently are 190,802 NPs in the U.S., or 60 per 100,000 population. There are 11,074 NPs in Texas, or 42 per 100,000 population, less than the national average. There are 104,337 PAs in the U.S., or 33 per 100,000, while there are 6,898 in Texas, or 26 per 100,000. Texas has fewer advanced practitioners than the national average and will need to train and attract more to supplement (though not to replace) the physician workforce. EMPLOYMENT, CONSOLIDATION AND AFFILIATIONS For a variety of reasons, a growing number of physicians are seeking employment by hospitals. Hospital employment may be seen by physicians as a safe harbor from increasing government and third party payer compliance issues, escalating costs, flat or declining reimbursement, electronic health record (EHR) implementation, and other challenges physicians face in today s evolving healthcare market. The changing nature of the physician search assignments that Merritt Hawkins conducts nationally reflects this trend. In 2004, 11% of Merritt Hawkins search assignments featured settings in which the recruited physician was to be employed by a hospital. By 2014, that number grew to 64% (see chart below). Merritt Hawkins Search Assignments Featuring Hospital Employment of Physicians % % % % % % % % % % % Source: Merritt Hawkins 2014 Review of Physician and Advanced Practitioner Recruiting Trends A growing number of other entities in addition to hospitals also are employing physicians, including large medical groups, urgent care centers, health insurance companies, retail clinics, FQHCs, surgery centers and others. According to Merritt Hawkins data, over 90% of newly hired physicians in 2014 were employed by a hospital, medical group or other entity, while fewer than 10% were recruited into a private practice (Merritt Hawkins 2014 Review of Physician and Advanced Practitioner Recruiting Incentives). A list of hospitals in Texas that are potential physician employers, showing in some cases the number of physicians on staff, is included in Appendix C of this report. 75 P a g e

78 A study of physician practice arrangements released by the American Medical Association in September, 2013, showed that a slight majority of physicians (53.2%) remain in self-employed, private practices (see chart below). Selected Findings of AMA 2013 Practice Arrangement Study Self-employed physicians, U.S 53.2% Self-employed physicians (under 40) 43.0% Self-employed (family practice) 39.8% Self-employed (internal medicine) 46.0% Self-employed (surgical subspecialties) 71.9% Self-employed (internal medicine subspecialties) 61.5% Self-employed, % Self-employed, % Self-employed, % Working in practices wholly owned by physicians 60.0% Working for practice wholly or partially owned by a hospital 29.0% Physicians in solo practice 18% (24% in 2007) Physicians in single-specialty practice 45.5% Source: Policy Research Perspectives: New Data on Physician Practice Arrangements: Private Practice Remains Strong Despite Shifts Toward Hospital Employment. American Medical Association. September, 2013 However, these numbers reflect 2012 data. The Physicians Foundation s 2014 Survey of America s Physicians, based on 2014 data, shows a lower number of physicians now in private practice (see chart below) and may be more indicative of a market rapidly evolving toward the employed physician model. Practice Status of U.S. Physicians Employed by a hospital 30.5% Employed by a medical group 22.4% Practice owner/partner/associate 34.6% Other 12.5% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins These data suggest that only about 35% of physicians remain in self-employed status nationwide, while the remainder are either employees or in other practice status that may be considered quasiemployed or quasi-independent, depending on one s perspective. As a sign of the future, a greater number of younger physicians indicate they are employed than do older physicians (see chart below): Practice Status of Physicians by Age 45 or younger 46 or older Employed by a hospital or group 65.7% 25.7% 76 P a g e

79 Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins It is widely perceived that younger physicians are less inclined to be interested in private practice than are older physicians, as they put a greater premium on personal time and lifestyle considerations. In Merritt Hawkins 2015 Survey of Final-Year Medical Years, 76% of physicians completing their training in 2014 indicated they would prefer employment by a hospital, medical group or other entity to an employed setting in their first practice. As referenced above, Texas remains one of the last bastions of independent practice, but even in Texas, with its corporate practice of medicine law, less than 50% of physicians are independent (see chart below). Independent Physicians by State 1 Louisiana 52.0% 26 New York 33.2% 2 Texas 48.6% 27 Rhode Island 32.9% 3 New Jersey 44.6% 28 Virginia 32.9% 4 Illinois 44.2% 29 West Virginia 32.9% 5 Arkansas 43.3% 30 Delaware 31.1% 6 Hawaii 42.4% 31 Ohio 30.6% 7 Idaho 41.9% 32 Iowa 30.4% 8 Arizona 39.2% 33 Nebraska 29.6% 9 Utah 38.2% 34 Pennsylvania 29.1% 10 Tennessee 38.1% 35 Kentucky 28.6% 11 Alabama 37.9% 36 Kansas 28.3% 12 Nevada 37.9% 37 Maryland 27.6% 13 Michigan 37.8% 38 Missouri 27.6% 14 North Carolina 37.7% 39 Oklahoma 25.8% 15 Connecticut 37.1% 40 Maine 24.4% 16 South Carolina 37.0% 41 Vermont 22.9% 17 Georgia 36.5% 42 Minnesota 22.7% 18 California 36.3% 43 Massachusetts 22.6% 19 Florida 36.2% 44 Alaska 19.4% 20 Wyoming 35.3% 45 Indiana 19.2% 21 Colorado 34.3% 46 New Mexico 18.4% 22 Washington 33.7% 47 New Hampshire 18.3% 23 Mississippi 33.3% 48 South Dakota 16.7% 24 Montana 33.3% 49 Wisconsin 12.0% 25 Oregon 33.3% 50 North Dakota 6.6% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins P a g e

80 As these numbers show, Texas has the second highest number of independent physicians after Louisiana. This number was corroborated by independent data obtained through physician data firm SK&A, which indicate 45% of Texas physicians remain in independent practice (see chart below). Independent/ Group Medical Practice (GMP) Affiliations /Employed Physicians in Texas 2% 10% 36% 7% 45% Independent (45%) Traditionally Employed (36%) Employed by GMP affiliated with Hospital System (10%) Employed by GMP affiliated with Large Independed Group (7%) Employed by GMP affiliated with National Group (2%) Source: SK&A, 2014 These employed or affiliated arrangements can be illustrated by listing some of the more prominent physician organizations in Texas, the number of physicians in each, and their practice arrangement (i.e., whether independent or affiliated) as well as the largest health systems in Texas and the number of physicians affiliated with each (see charts below): Hospital, Large Medical Group, and National Organization Affiliations Employed by GMP affiliated with Hospital System Employed by GMP affiliated with Large Independent Group Employed by GMP affiliated with National Group Group Medical Practice Physician Count Hospital or Affiliation Description Scott & White Clinic 930 Baylor Scott & White Health System Health Texas Provider Ntwk 480 Baylor Scott & White Health System UT Physicians Houston 429 UT Health System Texas Health Physicians Group 386 Texas Health Resources Health System Texas Oncology PA 368 Independent oncology practice with more than 375 physicians Cook Childrens Hematology & Onc 318 Cook Children s Health System Kelsey-Seybold Clinic 306 CHI- National HC System UT Medicine San Antonio 304 UT Health System Austin Regional Clinic 274 Independent group employs 285 physicians Pinnacle Anesthesia Consultants 231 Independent group employs 325 physicians FM 1960 Pediatric Center 210 Texas Children's Hospital (Affiliated with Baylor School of Med) 78 P a g e

81 Greater Houston Anesthesiology 202 Independent group employs over 300 physicians Trinity Clinic Primary Care 193 Trinity Mother Frances Hospitals and Clinics USMD 189 Independent group employs more than 250 physicians Pediatrix Medical Group 171 MEDNAX National Group- Employs more than 1600 Covenant Medical Group 148 Independent group employs over 600 physicians Texas Health Care PLLC 142 Independent group employs over 140 physicians Shannon Clinic 135 Shannon Health System Emergency Service Partners 131 Independent group employs over 300 providers Star Anesthesia 125 Independent group employs over 160 physicians Memorial Hermann Medical Group 121 Memorial Hermann Health System ETMC First Physicians 115 ETMC employs over 600 providers Wellmed 110 Wellmed- National HC System (TX & FL) Austin Diagnostic Clinic 107 Independent group employs over 120 physicians Radiology Associates Tarrant 100 Independent group employs over 120 (Radiology Associates of North Texas) Austin Radiological Association 94 Independent group employs more than 1500 (Strategic Radiology National Group) Tejas Anesthesia 87 Independent group employs over 80 physicians Baylor College Of Medicine 82 Baylor Medical School QuestCare 80 National HC System- Employs over 750 Diagnostic Clinic Of Longview P 79 Independent group employs over 90 physicians Collom & Carney Clinic 77 Independent group- Collom & Carney Clinic Association Texas Radiology Associates LLP 70 Independent group employs over 75 physicians Digestive Health Assocs Of TX 67 Independent group employs over 75 physicians IPC The Hospitalist Company 67 IPC Healthcare- Approximately 1,800 providers (national) CareNow 65 Independent group employs over 50 Physicians Capitol Anesthesiology Assocs 62 Independent group employs over 80 physicians Concentra Urgent Care 61 National HC System- more than 900 affiliated primary care physicians UNT Physicians Group 61 UNT Medical School Heart Place 59 Independent group employs over 70 physicians Austin Anesthesiology Group 58 Independent group employs over 65 physicians Beaumont Radiology Associates 56 BHS Physicians Network- independent group employs over 90 physicians Christus Medical Group 55 CHRISTUS Health System Houston Eye Associates 54 Independent group employs over 60 physicians South Texas Radiology 54 South Texas Radiology Group, P.A. - independent employs 60 physicians Family Healthcare Associates 52 Independent group employs over 50 physicians Dallas Nephrology Associates 52 Independent group employs over 70 physicians Fresenius Medical Group 52 National HC provider- employs 60,000 total Ameripath 42 National Group- Employs 400 pathologists and Ph.D.- level scientists 79 P a g e

82 Nextcare Urgent Care 38 National Group- 100 locations in 11 states EmCare Nationwide 31 EmCare has more than 700 exclusive contracts with client hospitals in nearly 42 states Planned Parenthood 10 National Group- Employs 27,000 (Volunteers included) Source: SK&A, 2014 Health System Top 10 Largest System Affiliations Physician Count Texas Health Resources (Arlington TX) 1,719 Baylor Health Care System (Dallas TX) 1,596 Memorial Hermann Health System (FKA: Memorial Hermann Healthcare System) (Houston TX) 1,582 HCA North Texas Division (Irving TX) 1,016 Houston Methodist (FKA: Methodist Hospital System) (Houston TX) 918 HCA Gulf Coast Division (Houston TX) 834 Scott & White Memorial Healthcare (Temple TX) 772 Community Health Systems (CHS) (Franklin TN) 736 Methodist Health System Of San Antonio (San Antonio TX) 719 St David s Healthcare (Austin TX) 684 Source: Definitive Healthcare Database, 2014 As the healthcare system evolves, physician relationships with various entities are likely to become more complex, as are the relationships with other often free-standing businesses. Just as it may be difficult to know what corporation owns or is affiliated with a restaurant, it will become more difficult for consumers to trace the ownership or affiliation status of the physicians they see. Some physicians with offices on hospital campuses may be independent, while some in traditional corner offices may be hospital employed. Texas reflects this trend, with recent noted consolidation activity including the landmark merger between the Baylor hospital system and the physician-owned Scott & White clinics. The 2013 merger created a sprawling health system composed of 43 hospitals, 500 patient care sites of service, and over 6,000 affiliated physicians. Similarly, in 2011, Texas Health Resources, a North Texas based system composed of 25 hospitals, acquired Medical Edge Healthcare Group, a medical group composed of some 420 physicians, physician assistants and nurse practitioners with 250 patient access points. Other physician groups in Texas have grown through consolidation. An example is USMD (formerly, Medical Clinic of North Texas), which in 2000 was composed of 56 physicians in four specialties, but due largely to consolidation grew to 130 physicians in nine specialties by USMD now has 211 physicians in 16 specialties after merging with Urology Associates of North Texas. These evolving relationships are being given impetus in part by the growing limits the Texas legislature is placing on the statewide ban on the practice of corporate medicine, which prohibits hospitals from employing physicians. In 2011, then Governor Rick Perry signed into law a bill that expands those hospitals that qualify for an exception to the ban. The law allows critical access hospitals, sole community hospitals, and hospitals in counties with populations of 50,000 or less (nearly 200 of the 80 P a g e

83 state s 254 counties) to employ physicians. The legislature made similar concessions in the past for private nonprofit medical schools, school districts, some non-profit health organizations and certain hospital districts. It is generally believed that an end to the ban is probable somewhere in the future. POPULATION MANAGEMENT AND ACCOUNTABLE CARE ORGANIZATIONS (ACOs) The ACA, combined with market forces that are driving health insurance costs for companies and individuals to unsustainable levels, is driving much of this consolidation and integration. It is believed by many policy analysts and healthcare professionals that integrated health systems composed of hospitals, doctors, management teams, and robust information technology resources offer the best model to control costs and ensure quality. The ACA encourages the formation of Accountable Care Organizations (ACOs) that implement this model, are designed to manage the health of large populations, and are financially rewarded for cost effectiveness and for achieving positive health outcomes for patients. An increasing number of physicians nationally and in Texas are affiliated with an ACO (see charts below): Texas Physicians Affiliated with ACOs 23% 77% ACO Affiliated No ACO Affiliations Health Record Type 1% 99% Group Medical Practice Accountable Care Organization 81 P a g e

84 Top ACO Affiliated by Counties 38% 22% 18% HARRIS DALLAS COLLIN TARRANT BELL REMAINING COUNTIES 7% 7% 8% ACO Initiated By: 3% 39% 29% Hospital Integrated Health System Payer Physician 29% Source: SK&A, 2014 While SK&A indicates 23% of Texas physicians are affiliated with ACOs, The Physicians Foundation s 2014 Survey of America s Physicians indicates a slightly lower number and suggests Texas ranks 39 th out of 50 states in physician ACO participation (see chart below): Physicians Participating in ACOs by State 1 Vermont 56.3% 26 North Dakota 25.8% 2 Wisconsin 47.8% 27 Arkansas 24.8% 82 P a g e

85 3 New Hampshire 46.6% 28 Missouri 23.6% 4 Massachusetts 44.6% 29 Rhode Island 23.6% 5 Iowa 40.4% 30 Virginia 23.6% 6 Oregon 39.5% 31 West Virginia 23.6% 7 Maine 37.5% 32 Kentucky 23.5% 8 Minnesota 37.3% 33 North Carolina 23.3% 9 Michigan 34.5% 34 South Carolina 22.5% 10 Idaho 33.3% 35 Colorado 21.7% 11 Connecticut 32.6% 36 Tennessee 21.7% 12 Indiana 32.6% 37 Maryland 20.9% 13 Illinois 32.4% 38 New Mexico 20.6% 14 Hawaii 30.6% 39 Texas 19.5% 15 Ohio 30.3% 40 Montana 18.9% 16 Georgia 28.6% 41 Oklahoma 18.7% 17 South Dakota 28.6% 42 Alaska 18.4% 18 Washington 28.6% 43 Pennsylvania 18.3% 19 Nebraska 28.4% 44 Florida 17.7% 20 New Jersey 28.3% 45 Delaware 17.6% 21 Arizona 27.7% 46 Mississippi 16.8% 22 Nevada 27.4% 47 Alabama 13.4% 23 California 26.9% 48 Wyoming 11.8% 24 New York 26.0% 49 Louisiana 11.2% 25 Utah 26.0% 50 Kansas 9.4% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins Currently, CMS indicates there are 337 Medicare designated ACOs nationwide. As of May 2014, Leavitt Partners is actively tracking 626 ACOs of all kinds (Medicare and non-medicare) across the United States. Of these 626 ACOs, 329 have government contracts, 210 have commercial contracts and 74 have both government and commercial contracts. The remaining 13 ACOs have not made specific announcements about the nature of their accountable care contracts or are in the process of finalizing contracts that are not yet active. Source: Petersen, M., Gardner, P., Tu, T., & Muhlestein, D. (2014, June 1). Growth and Dispersion of Accountable Care Organizations: June 2014 Update. In Texas, there are 49 ACOs (see list below), which cover about 5-10% of Texas population, with higher penetration in urban areas of the state. Many counties have no ACOs, while some counties have multiple ACOs (see graphics below). ACO Facilities Associated With Physicians in Texas Accountable Care Coalition Of Greater Athens Georgia I Accountable Care Coalition of Greater Houston, LLC. Accountable Care Coalition Of North Texas LLC Methodist Patient Centered ACO Patient Physician Network & Cigna Physicians ACO LLC 83 P a g e

86 Accountable Care Coalition Of Texas Inc ACO Providers Adventist Health Network Cigna AllCare IPA & Doctors Medical Center & Blue Shield Of California Amarillo Legacy Medical ACO Baptist Health System/HealthTexas Medical Group & Aetna Baylor Quality Alliance BHS Accountable Care LLC Buena Vida Y Salud Covenant Health Partners Essential Care Partners Essential Care Partners II LLC Fresenius Medical Care North America & Aetna Genesis Accountable Physician Network, LLC HealthTexas Provider Network & Cigna Heritage California ACO Heritage Provider Network & Anthem Blue Cross Of California Integrated ACO LLC Medical Clinic Of North Texas & Cigna Medical Clinic Of North Texas PLLC Memorial Hermann Accountable Care Organziation Meridian Health Systems ACO Corporation Plus Accountable Care Organization Premier Family Southwest Medical Village Premier Patient Healthcare LLC Renaissance Physiciaan Organization & Cigna Renaissance Physician Organization RGV ACO Health Providers, LLC Rio Grande Valley Health Alliance, LLC Scott & White Healthcare Walgreens Well Network LLC Seton Health Alliance Seton Health Alliance & Aetna Seton Health Alliance & UnitedHealth Care SSM ACO LLC & Anthem Blue Cross Blue Shield St Joseph Health Partners ACO St Lukes Episcopal Hospital Independent Practice Association INC & Cigna Sunshine ACO LLC SW Provider Partners LLC Tenet Healthcare Corporation & Humana INC Texas Health Resources & Aetna Texoma ACO LLC UPSA ACO UT Southwestern Accountable Care Network Sources: SK&A and CMS.gov Estimated ACO Penetration by State 84 P a g e

87 Source: Leavitt Partners Center for Accountable Care Intelligence Estimated ACO Penetration by Hospital Referral Region Source: Leavitt Partners Center for Accountable Care Intelligence In more than half of states, a majority of people have access to an ACO Updated as of January 2014 Sources: News releases, company websites, Dartmouth Atlas PCSAs, Claritas, Oliver Wyman analysis 1. ACOs defined as providers participating in Pioneer ACO, Medicare Shared Savings, a Medicaid ACO, PGP Transition, or in a shared savings/risk arrangement with a commercial payer; Prep activity defined as participation in a learning collaborative or providers preparing to become an ACO 85 P a g e

88 MSSP and Pioneer ACO Counts by County Source: Centers for Medicare and Medicaid Services, 2014 It is difficult to determine how many Texas physicians are affiliated with each ACO on the above list. However, as the data above show, the total is between 19.5% (9,155 physicians) and 23% (10,799 physicians). The ultimate success of this model, and whether or not these ACOs will prosper or survive, is still an open question. However, reimbursement systems for both hospitals and physicians, led by CMS, clearly are moving away from volume based models and toward value-based models. On January 27, 2015 federal officials announced an accelerated effort to shift payment from volume to value based metrics. The goal is to grow value-based Medicare payment to 50% by the end of 2018, a move likely to promote physician/hospital affiliation and the employment of physicians in Texas and nationally. Some form of organization such as ACOs, which can manage the health of large populations within a fixed budget, are likely to be prevalent in the future, and a significant number of physicians will be affiliated with them. MEANINGFUL USE The ACA has encouraged the adoption of electronic health records (EHR) by physicians in order to improve quality, increase efficiency, and promote care integration. Funds have been provided by the federal government for physicians who adopt EHR and follow Meaningful Use guidelines. The chart below shows the number of physicians in Texas and others states who have implemented EHR in their practices: Physicians Who Have Implemented EHR by State 1 Wisconsin 95.4% 26 Tennessee 87.4% 86 P a g e

89 2 North Dakota 95.2% 27 Kansas 87.3% 3 South Dakota 95.2% 28 Utah 87.1% 4 Minnesota 95.1% 29 California 86.7% 5 Wyoming 93.7% 30 Michigan 86.5% 6 Indiana 92.4% 31 Oklahoma 86.4% 7 Iowa 91.8% 32 Maryland 85.6% 8 Oregon 91.8% 33 Arizona 85.5% 9 Nebraska 91.5% 34 Idaho 85.5% 10 Missouri 90.1% 35 Georgia 85.1% 11 New Hampshire 89.3% 36 Illinois 84.8% 12 Rhode Island 89.0% 37 Maine 84.8% 13 Virginia 89.0% 38 Nevada 84.5% 14 West Virginia 89.0% 39 Pennsylvania 84.2% 15 Massachusetts 88.6% 40 South Carolina 84.2% 16 Washington 88.3% 41 Alaska 83.8% 17 Delaware 88.2% 42 Kentucky 83.8% 18 Colorado 87.9% 43 Mississippi 83.8% 19 North Carolina 87.7% 44 Hawaii 82.4% 20 Alabama 87.5% 45 Florida 82.3% 21 Arkansas 87.5% 46 Connecticut 80.0% 22 Montana 87.5% 47 New York 79.8% 23 Vermont 87.5% 48 Texas 79.5% 24 New Mexico 87.4% 49 Louisiana 77.3% 25 Ohio 87.4% 50 New Jersey 73.8% Source: A Survey of America s Physicians. The Physicians Foundation/Merritt Hawkins Though the majority of Texas physicians have implemented EHR, Texas has a low rate of physician EHR implementation relative to other states. Stage 1 Meaningful Use Payments Received in Texas: This information was available for a smaller population of the total 39,237 physicians listed in the Excel spreadsheet attached to this report. Only 30,891 were reviewed in this section. Payment amount per physician accumulated from for Stage 1 Meaningful Use requirements met (Medicare Only): OVERALL PRIMARY CARE SPECIALIST PHYSICIAN COUNT: 12,513 3,830 8,683 TOTAL AMOUNT: $314,549, $97,016, $217,532, AVERAGE: $25, $25, $25, HIGH: $41, $41, $41, LOW: $2.00 $2.00 $ P a g e

90 Percentage of Meaningful Use Payments Given 24.67% 14.23% 59.49% $0 $999 $1,000-$9,999 $10,000-$24,999 $25, % 0.13% Source: Definitive Healthcare, 2014 General Information: More than $17.2 billion in Medicare EHR Incentive Program payments have been made between May 2011 and November More than $8.7 billion in Medicaid EHR Incentive Program payments have been made between January 2011 (when the first set of states launched their programs) and November State Program Type Provider Type Count Amount Average/Provider Texas Medicare EP 30,190 $406,134, $13, Source: Centers for Medicare & Medicaid Services, cms.gov, May 2014 It is to be hoped that EHR will increase physician productivity and allow more time for patient care, thereby enhancing some of the physician FTEs lost to changing physician work patterns and choices enumerated above. 88 P a g e

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