• How we pay to train pediatricians

    I learned something new about pediatric residency training in the NEJM*:

    On October 1, 2013, without a continuing resolution in place to support its budget, the U.S. federal government partially closed. One of many effects of the government shutdown was the defunding of the Children’s Hospitals Graduate Medical Education (CHGME) Payment Program. Fifty-five freestanding children’s hospitals currently receive CHGME funds. These hospitals train almost 30% of the general pediatricians, 44% of the pediatric medical and surgical subspecialists, and the majority of the pediatric physician-researchers in the United States. Capable of providing highly specialized care for pediatric patients with complex and acute conditions, freestanding children’s hospitals are at the apex of many pediatric referral networks. The sudden lapse in CHGME funding represents only the most recent financial challenge for children’s hospitals providing residency training and highlights the danger of subjecting the larger universe of Medicare funding for graduate medical education (GME) to a highly politicized process.

    The CHGME program was created in 1999 under the Healthcare Research and Quality Act to provide financial support for GME at eligible freestanding children’s hospitals. Historically, Medicare GME subsidies have been linked to care provided at teaching hospitals for Medicare beneficiaries, who are, with rare exception, adults. As a result, over the years since the inception of Medicare in 1965, freestanding children’s hospitals had received essentially no federal support for residency or fellowship training. The CHGME program was developed to provide partial parity in federal funding for training programs at these hospitals by creating a process similar, but not identical, to Medicare GME. One key difference between the two programs is that the Medicare GME program is financed through the Medicare Trust Fund, and the CHGME Payment Program relies on annual funding allocated through the political process of annual congressional appropriations.

    Most residency programs are paid for by Medicare. However, almost no Medicare money flows to children’s hospitals, which train many pediatricians. So the CHGME program was established. Unlike Medicare, however, the CHGME program is subject to the regular budget. That means that like other spending, that going to train pediatric residents has gone down 21% in the past three years. How in the world are we expecting to train the same number (let alone more) pediatricians with that much less money?

    With this year’s CHGME funding appropriation far from certain, pediatric residents and fellows are being paid out of clinical and other reallocated revenue — which undoubtedly creates pressures in other parts of the children’s health care system. Though this stopgap measure helps to continue the training of pediatricians and the care of their patients, we hope that in the future, GME funding can avoid being caught in this type of political tug-of-war.


    *One of the authors was the director of my residency training program. I tell you this for full disclosure. I feel a lot of gratitude towards him, and quite a bit of sympathy as well. I was not the easiest resident to deal with.


    • To emphasize the importance of this issue, neonatal physicians, the sub-specialists who care for newborns with complex or acute health issues, are pediatricians with additional training. I’ve had the privilege of advising and observing neonatologists, and the work they do is phenomenal.

    • Aaron,
      I’m a pediatrician as well and trained at a stand alone children’s hospital. I am sympathetic to the need to train pediatricians, however if you take one step further back on the finances of these stand alone children hospitals you may not be quite as impressed with their plea of poverty. Their have been recent reports about the “profitability” (I place in quotes because they are all non-profits) and executive pay at stand alone children hospitals and because they often have such large market shares they make money hand over fist. They also have foundations which raise millions. While these program cuts may not be fair conpared to adult funding of GME activities, the margins on their clinical activities is very different from adult hospitals as well. It would be interesting for you to comment on their overall finances when their spokesman report that they are worried about how the cost of GME creates pressure on other systems. They could decide not to have residents but then hiring attendings to relieve the clinical load would likely be as if not more costly.


    • The fact that we rely on Medicare to pay for residency training is messed up — it relieves others of the responsibility, forces more training to take place in the hospital than should occur, and then creates problems for non-Medicare intensive specialties. We use residents when we should be using other clinical personnel. But no one wants to upset the apple cart or redistribute the money. It makes no sense and yet perfect sense all at the same time.

      • That’s an interesting point, Fred. I hadn’t really associated residency funding with the hospital heavy training that US physicians receive. In Europe medical graduates are tracked into specialty care or primary care and those in the latter track receive a lot more outpatient training than US PCPs. It’s not that taking care of hospital patients isn’t an important skill set for the PCP, but once you’ve dried out a dozen or so congestive heart patients, for instance, it’s become automatic. Keeping them dry as an outpatient is a much trickier business and not nearly as well taught.

        Our current method of funding graduate education doesn’t just push young docs in the direction of specialties, it actively discourages better outpatient and primary care skills.

    • Yet in spite of all these challenges, including regular disrupted funding for the CHGME program, pediatrics residency slots continue to increase nationwide.

      In fact, pediatrics residency slots are one of the fastest increasing residency slots over the last 10 years.

      This is much ado about nothing. Hospitals will adjust. Peds residency programs will not be closing en masse.

      Link: NRMP Charting the Match: http://b83c73bcf0e7ca356c80-e8560f466940e4ec38ed51af32994bc6.r6.cf1.rackcdn.com/wp-content/uploads/2013/08/resultsanddata2013.pdf