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.


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