Even if you don't live in Texas, these numbers should scare anyone who cares about rural healthcare, because this crisis is not unique to Texas.
How bad is the provider shortage in Texas?
- 185 counties in the Lone Star State with a combined population of more than 3.1 million people, equal to or greater than 21 states, have no psychiatrist.
- 158 Texas counties with a combined population of 1.9 million, equal to or greater than 14 states, have no general surgeon.
- 147 Texas counties with a combined population of more than 1.8 million people have no obstetrician/gynecologist.
- 80 counties have five or fewer physicians.
- 35 counties have no physician.
Even if you don't live in Texas, these numbers should scare anyone who cares about rural healthcare, because this crisis is not unique to Texas, which ranks 41st among 50 states in physicians per 100,000 residents.
"We're saying that more than 3 million people in the state of Texas don't have a psychiatrist. That is like saying Kansas doesn't have a psychiatrist. That is like saying the state of Nebraska or Montana doesn't have an OB. It's incredible," says Travis Singleton, senior vice president of Merritt Hawkins, who compiled the survey for NTREC.
"Sometime you have to put it that way to make people understand what we face."
Loving County, TX, population 95, has no physicians. Neither does King County, population 283.
However, Live Oak County has no physicians for its 11,867 residents. Jackson County, population 14,591, has two physicians. The bottom line is that there are few and often no physicians across wide stretches of this stretched-wide state. Singleton says Texas would need to add more than 12,800 physicians to put it in the national average of physicians per 100,000 population.
As a result of the shortage, many residents of rural Texas are forced to travel to the next county or further to access healthcare.
"Some say you are manipulating data. Some of those counties don't have that many people and don't justify having an OB anyway. Yes, you do have a couple with 95 or 100 people. You will also have counties with 77,000 people in them without access," Singleton says.
"It also shows you how the problem is compounded by maldistribution. The vast majority of practitioners are in Dallas, Houston, San Antonio and Austin and this shows you what a strain that puts on the rest of the state. If you are an OB and you have your choice to go anywhere in the state, why would you go to a rural county with no support?"
Singleton makes a living tracking physician shortages across the nation for Merritt Hawkins, and he says that, while the survey is unique to Texas, the findings are not.
"To a lesser or grander scale you are going to see this everywhere," he says. "In fact, Texas has done better than most at attracting advanced practice nurses and physicians to meet population demands through tort reform or state-funded loan forgiveness and other programs."
Richard Howe, executive director of NTREC, says he hopes these stark numbers will open some eyes among Texas urbanites.
"There were some surprises. Those of us in urban areas think there are plenty of physicians and we have a high number of physicians per capita in urban areas," Howe says. "But you don't have to get far out of Dallas and it jumps rural pretty quick. We didn't realize how void some of these medical specialties would be throughout the state of Texas."
The lack of access to psychiatrists is particularly insidious because of the linkage between mental and physical health.
"That population with obesity, diabetes, (chronic obstructive pulmonary disease), and congestive heart failure is the same population, way above the averages, for individuals with needs for mental health services," Howe says. "If you don't have mental health capacity in the state, that is going to have a big impact on healthcare in general and will increase our incidences of these chronic diseases.
Urban Shortages Too
The physician shortage isn't just in rural Texas. Urban Texas is feeling the provider pinch within primary care. There are 375 federally designated Health Care Professional Shortage Areas in Texas with a dearth of primary care physicians and many of them are in the state's most populous counties, including Dallas, Harris, and Bexar.
Texas ranks second in the nation in the percentage of physicians who remain in independent private practice, although more physicians in the state are turning to hospital employment, part-time practice, and concierge medicine that reduce hours and accessibility. They also are less likely to accept Medicaid and Medicare payments than physicians in other states.
"It's not just the rural isolated counties where it is the issue," Singleton says. "You could be in downtown Dallas, depending on what kind of patient you are and what kind of provider you need, and you could have an issue. Five or 10 years ago you could look at a provider map and say are they employed or independent? Now you need to know practice patterns, who they are affiliated with, what resources do they have, are they urgent care, concierge? You just can't say they are family practitioners anymore."
Armed with the new survey data, Howe says the 88 hospitals that formed NTREC will go to the Capitol in Austin to push for remedies. "There is a shortage of physicians in Texas," he says. "When we did this study we kind of felt there was a shortage, but we didn't know it was to this extent. One of the areas we can lobby for is better education and more money for medical education."
Howe says the information could bolster efforts to expand Medicaid in Texas.
"The state of Texas is turning down millions of Medicaid dollars every year and people say we don't want to be tied to the rules of Medicaid. Well, we are already," he says. "Those people come into the emergency department and they're accessing areas where our healthcare expenditures are very high instead of having more Medicaid dollars to treat them in a community setting."
Singleton believes that the survey will provide a wake-up call for Texas' politicians and policy makers.
"It is one thing to know you are in the middle of a drought, but quite another to walk down to the lake and see it almost bone dry," he says. "It really puts a different perspective on it. A study like this can show you that."
John Commins is a senior editor at HealthLeaders.