U.S. GOVERNMENT PUBLISHING OFFICE

33–535 WASHINGTON : 2019

REAUTHORIZATION OF THE CHILDREN’S 

HOSPITAL GRADUATE MEDICAL EDUCATION 

PROGRAM 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

MAY 23, 2018 

Serial No. 115–135 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

JEFF DUNCAN, South Carolina 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

(III) 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, TEXAS

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MARSHA BLACKBURN, Tennessee 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(V) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Prepared statement .......................................................................................... 5 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 6 

Prepared statement .......................................................................................... 7 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 32 

WITNESSES

Gordon E. Schutze, M.D., Professor of Pediatrics, Executive Vice President 

and Chief Medical Officer, Baylor International Pediatric Aids Initiative, 

Texas Children’s Hospital ................................................................................... 9 

Prepared statement .......................................................................................... 11 

Susan Guralnick, M.D., Associate Dean for Graduate Medical Education, 

University of California, Davis ........................................................................... 16 

Prepared statement .......................................................................................... 18 

SUBMITTED MATERIAL

Statement of the American Academy of Pediatrics .............................................. 33 

Statement of the Children’s Hospital Association ................................................ 35 

Statement of the Healthcare Leadership Council ................................................. 36 

Statement of the American Hospital Association ................................................. 38 

(1) 

REAUTHORIZATION OF THE CHILDREN’S HOSPITAL GRADUATE MEDICAL EDUCATION 

PROGRAM 

WEDNESDAY, MAY 23, 2018 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 1:00 p.m., in room 

2322 Rayburn House Office Building, Hon. Michael Burgess (chairman of the subcommittee) presiding. 

Members present: Representatives Burgess, Guthrie, Upton, 

Shimkus, Blackburn, Latta, Lance, Bilirakis, Long, Bucshon, 

Brooks, Mullin, Hudson, Collins, Carter, Green, Schakowsky, Matsui, Schrader, Kennedy, and DeGette. 

Staff present: Daniel Butler, Staff Assistant; Zachary Dareshori, 

Legislative Clerk, Health; Ed Kim, Policy Coordinator, Health; 

Kristen Shatynski, Professional Staff Member, Health; Jennifer 

Sherman, Press Secretary; Austin Stonebraker, Press Assistant; 

Jeff Carroll, Minority Staff Director; Tiffany Guarascio, Minority 

Deputy Staff Director and Chief Health Advisor; and Samantha 

Satchell, Minority Policy Analyst. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. We thank all of our guests for being with us today. 

I call the subcommittee to order. I recognize myself 5 minutes for 

the purpose of an opening statement as we convene the legislative 

hearing on H.R. 5385, the reauthorization of the Children’s Hospital Graduate Medical Education Program. 

This legislation, authored by Ranking Member Green and the 

chairman of this very subcommittee, is important in ensuring that 

we have adequate financial support for our pediatric workforce of 

the future. 

Prior to the establishment of Children’s Hospitals Graduate Medical Education, the hospitals received minimal education funding 

because Medicare is the primary funding source for graduate medical education programs and children’s hospitals have few Medicare 

patients. In 1999, Congress created the Children’s Hospitals Graduate Medical Education program as part of the Healthcare Research and Quality Act which authorized funding to directly support medical residency training at children’s hospitals for a period 

of 2 years. 

2 

This program is especially crucial in training our pediatric subspecialists. Children’s hospitals have a unique patient population 

with medical conditions from which pediatric medical residents can 

learn and develop critical skills. The experience gained from such 

a residency helps prepare and train physicians for the complex reality of pediatric medicine that they will face in the future of their 

medical careers. Certainly, as someone who spent his career as an 

OB/GYN and did his residency at Parkland Hospital, I know that 

residency programs play a vital role in shaping our nation’s physician workforce. Our pediatric workforce of course is no exception. 

Before us today are witnesses who will be able to explain to us 

the substantial role That Children’s Hospital Graduate Medical 

Education plays in the ability of children’s hospitals to build a 

strong pediatric workforce. Currently these hospitals face a workforce shortage which has led patients and their families to suffer 

through long waiting periods to book even just an initial appointment with pediatric specialists and subspecialists. 

According to the Children’s Hospital Association, almost half of 

children’s hospitals reported vacancies for child and adolescent psychiatry in addition to developmental pediatrics. The Children’s 

Hospital Association also reports that pediatric specialists in emergency medicine, physical medicine, rehabilitation, endocrinology, 

rheumatology, hospitalists, pain management, palliative care, and 

adolescent medicine are frequently reported as experiencing vacancies longer than 12 months. The workforce shortage is something 

that I am concerned about and we are all working to correct. Passing this legislation is an integral part in maintaining and sustaining our workforce. In calendar year 2016, Children’s Hospital 

Graduate Medical Education funding helped to support well over 

7,000 residents at 58 hospitals across the country. 

Our children do deserve the best care available to them and ensuring that we have adequately prepared our pediatric workforce 

is the first step in providing quality care to our children. Hospitals 

that receive this funding train nearly half of our nation’s pediatricians and pediatric subspecialists. This bill will authorize $330 million per year in funding for fiscal years 2019 through 2023 for the 

Children’s Hospital Graduate Medical Education program. This is 

a $30 million per year increase in this funding which has only been 

appropriated at a level of around 300 million for each of the past 

5 years. 

I should say parenthetically I learned something about the President’s budget from Children’s Graduate Medical Education, it is always zeroed out by the administration whether it is a Democratic 

or a Republican administration. The Bush administration zeroed it 

out. The Obama administration zeroed it out, Trump administration, and it is always up to this committee to bring those dollars 

back. 

So that is the happy course that we are embarked upon in partnership today. Texas Children’s Hospital, one of the top five children’s hospitals in the country is represented today by Dr. Gordon 

Schutze. 

Dr. Schutze, obviously as the chairman and ranking member of 

the committee, this is a Texas-focused, Texas-centric committee 

3 

and we want to give you a warm welcome and thank you for being 

willing to testify before us today. 

Dr. Guralnick, thank you to you for providing your time and expertise for us as well. 

Texas Children’s Hospitals are primarily partners with Baylor 

College of Medicine, which is one of the largest academic pediatric 

departments in the United States, with over 1,300 faculty members. Texas Children’s has well over a thousand people training in 

hospital GME programs which amounted to over $42 million in 

costs in 2017 and almost 11 million of that or about 25 percent was 

covered by Children’s Graduate Medical Education. Similarly, Children’s Health System of Texas has just $6 million of its $30 million 

in teaching programs covered by Children’s Hospital Graduate 

Medical Education. Needless to say, this program is vital in allowing children’s hospitals to maintain and grow their workforce especially as the need for new programs such child and adolescent psychiatry emerges. 

I want to thank our witnesses for testifying before us. I look forward to a productive discussion of this important legislation. I 

would yield to the gentlelady from Tennessee. 

[The prepared statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

Good afternoon, everyone. We convene today for a legislative hearing on H.R. 

5385, the reauthorization of the Children’s Hospital Graduate Medical Education 

(CHGME) program. This legislation, authored by the Ranking Member and Chairman of this very subcommittee, is incredibly important in ensuring that we have 

adequate financial support for our pediatric workforce. 

Prior to the establishment of CHGME, children’s hospitals received minimal graduate medical education funding because Medicare is the primary funding source of 

GME programs, and children’s hospitals have few Medicare patients. In 1999, Congress created the CHGME program as part of the Healthcare Research and Quality 

Act, which authorized funding to directly support medical residency training at children’s hospitals for 2 years. 

The CHGME program is especially crucial in training our pediatric subspecialists. 

Children’s hospitals have a unique patient population with medical conditions from 

which pediatric medical residents can learn and develop critical skills. The experience gained from such a residency helps to prepare and train physicians for the 

complex reality of pediatric medicine that they will face in the future of their medical careers. I can say as an OB/GYN who did his residency at Parkland Hospital 

in Dallas, that residency programs play a vital role in shaping our nation’s physician workforce. Our pediatric workforce is no exception. 

Before us today are witnesses who will be able to explain to us the substantial 

role CHGME plays in the ability of children’s hospitals to build a strong pediatric 

workforce. Currently, these hospitals face a workforce shortage, which has led patients and their families to suffer through exceedingly long waiting periods to book 

even just an initial appointment with pediatric specialists and subspecialists. 

According to the Children’s Hospital Association, 46.9 percent of Children’s hospitals reported vacancies for child and adolescent psychiatry, in addition to developmental pediatrics. The Children’s Hospital Association also reports that pediatric 

specialists in emergency medicine, physical medicine and rehabilitation, endocrinology, rheumatology, hospitalists, pain management/palliative care, and adolescent 

medicine are frequently reported as experiencing vacancies longer than 12 months. 

The workforce shortage is something that I am concerned about and working to 

combat—passing this legislation is an integral part in maintaining and sustaining 

our workforce. In 2016, CHGME funding helped to support 7,164 residents at 58 

hospitals across the country. 

Our children deserve the best care available to them, and ensuring we have an 

adequately prepared pediatric workforce is the first step in providing quality health 

care to our children. Hospitals that receive CHGME funding train nearly half of our 

nation’s pediatricians and pediatric subspecialists. This bill will authorize $330 milVerDate Nov 24 2008 09:58 Jan 17, 2019 Jkt 037690 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-135 CHRIS
4 

lion per year in funding for fiscal years 2019 through 2023 for the CHGME program. This is a $30 million per year increase in CHGME funding, which has only 

been appropriated at a level of $300 million for each of the past 5 years. 

Texas Children’s Hospital, one of the top five children’s hospitals in the country, 

is represented today by Dr. Gordon Schutze. Dr. Schutze, I want to give you a warm 

Texas welcome and thank you for testifying before us today. As one of the premier 

children’s hospitals and a leading teaching hospital, Texas Children’s is on the front 

lines of providing top-notch care for children from Texas and across the country. 

Texas Children’s Hospital primarily partners with Baylor College of Medicine, 

which is one of the largest academic pediatric departments in the United States, 

with over 1,300 faculty members. Texas Children’s has 1,153 people in training in 

hospital GME programs, which amounted to $42.7 million in costs in 2017—only 

$10.8 million, or about 25 percent, of which were covered by CHGME. Similarly, 

Children’s Health System of Texas has just $6 million of its $30 million in teaching 

program costs covered by CHGME. Needless to say, CHGME is vital in allowing 

children’s hospitals to maintain and grow their workforce, especially as the need for 

new programs such as child and adolescent psychiatry emerges. 

Thank you to both of our witnesses for testifying before us this morning. I look 

forward to a productive discussion of this important legislation. 

I would now like to yield the balance of my time to the gentlelady from Tennessee. 

Mrs. BLACKBURN. I thank the Chairman for yielding. And I want 

to say thank you to you all for being here today. When we talk 

about this program, we talk about it in Tennessee as being something that affects the delivery of medicine. St. Jude is a recipient 

of funds from this program. We know the good that it does. We 

want to make certain that there is sufficient accountability and 

transparency, so I thank the Chairman for the hearing and I yield 

back the balance of my time. 

Mr. BURGESS. The gentlelady yields back and the Chair now recognizes Mr. Green, Ranking Member of the Subcommittee, 5 minutes for your opening statement, please. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for holding this legislative hearing on the reauthorization of the Children’s Hospital 

Graduate Medical Education program and for working with me to 

introduce the Children’s Hospital GME support reauthorization, 

H.R. 5385, earlier this year. 

I want to thank our two panelists, Dr. Gordon Schutze, the Executive Vice Chair of Pediatrics at Texas Children’s Hospital in 

Houston, and Dr. Sarah Guralnick, Associate Dean for Graduate 

Medical Education at the University of California—Davis, for joining us today. It has pleased me that we are holding a hearing to 

reauthorize the payment program that has provided needed funding to train pediatricians since it was first authorized under the 

Healthcare Research and Quality Act. 

Dr. Burgess and I, as Chair and Ranking Member of this subcommittee have worked together to develop the legislation to reauthorize this vital program. The program, payment program was 

created to authorize payments to children’s hospital support needed 

in vital medical residency training programs. Although most hospitals typically receive GME funding through Medicare, pediatric 

hospitals treat very few patients enrolled in the Medicare program, 

denying these hospitals the similar support from the Federal Government for medical training. This program provides needed funding for training the pediatric workforce including pediatricians, peVerDate Nov 24 2008 09:58 Jan 17, 2019 Jkt 037690 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-135 CHRIS
5 

diatric subspecialists, neonatologists, pediatric psychiatrists, adolescent health specialists as well as other physician types in nonpediatric focused specialties that may rotate through children’s hospitals for a period of time during their residency. 

Since its creation, this payment program has made it possible for 

thousands of pediatricians to receive training. These physicians 

training in one of the 58 freestanding children’s hospitals throughout 29 states, District of Columbia, and Puerto Rico go on to serve 

in rural areas and other underserved areas helping to alleviate the 

pediatric workforce shortage. The program is needed now more 

than ever to help train the pediatric workforce that will be required 

to meet the needs of the growing pediatric demographic. 

The program fills a vital gap in health care by providing the 

funding needed to train pediatricians, pediatric specialists in many 

hospitals throughout the nation. The physicians train through the 

program to provide needed pediatric care throughout the United 

States including the children living in underserved and rural communities. I encourage my colleagues on the subcommittee to support the reauthorization of this vital program in order to help ensure there is enough pediatricians to provide needed healthcare 

services to our future generations of Americans. 

And, Mr. Chairman, you are so right. The President’s budget zeroed it out, but like you said, previous Presidents did. The beauty 

of the House of Representatives, thank goodness, is we write our 

own bills and we write our own appropriations bills so these vital 

programs can continue to be servicing. And thank you, Mr. Chairman. I yield back the remainder of my time. 

[The prepared statement of Mr. Green follows:] 

PREPARED STATEMENT OF HON. GENE GREEN

I would like to thank Chairman Burgess for holding today’s hearing on the reauthorization of the Children’s Hospital Graduate Medical Education Program, and for 

working with me to introduce the Children’s Hospital GME Support Reauthorization 

Act, H.R. 5385, earlier this year. 

I’d also like to thank our two panelists, Dr. Gordon Schutze, Executive Vice Chair 

of Pediatrics at Texas Children’s Hospital in Houston and Dr. Sarah Guralnick, Associate Dean for Graduate Medical Education at the University of California-Davis, 

for joining us today. 

It pleases me that we are holding today’s hearing to reauthorize the CHGME Payment Program that has provided needed funding to train pediatricians since it was 

first authorized under the Healthcare Research and Quality Act. 

Dr. Burgess and I, as the Chair and Ranking Member of this subcommittee, have 

worked together to develop legislation to reauthorize this vital program. 

The CHGME Payment Program was created to authorize payments to children’s 

hospitals to support needed and vital medical residency training programs. 

Although most hospitals typically receive GME funding through Medicare, pediatric hospitals treat very few patients enrolled in the Medicare Program, denying 

these hospitals similar support from the federal government for medical training. 

The CHGME provides needed funding for training the pediatric workforce, including pediatricians and pediatric subspecialists, such as neonatologists, pediatric psychiatrists, and adolescent health specialists, as well as other physician types in nonpediatrics-focused specialists that may rotate through children’s hospitals for a period of time during their residency. 

Since its creation, the CHGME Payment Program has made it possible for thousands of pediatricians to receive training. Those physicians receiving training in 1 

of the 58 free-standing children’s hospitals throughout 29 states, the District of Columbia, and Puerto Rico, go on to serve in rural and other underserved areas helping to alleviate the pediatric workforce shortage. 

6 

The CHGME is needed now more than ever to help train the pediatric workforce 

that will be required to meet the needs of the growing pediatric demographic. 

The CHGME Program fills a vital gap in healthcare by providing the funding 

needed to train pediatricians and pediatric specialists in many hospitals throughout 

the nation. The physicians trained through the program go on to provide needed pediatric care throughout the United States, including to children living in underserved and rural communities. 

I encourage my colleagues on the subcommittee to support the reauthorization of 

this vital program in order to help ensure that there will be enough pediatricians 

to provide needed healthcare services to future generations of Americans. 

Thank you, Mr. Chairman. I yield back the remainder of my time. 

Mr. GREEN. Anybody want it? Oh, Mr. Chairman, if you don’t 

mind, I would like to yield the remainder of time to my colleague 

from California. 

Mr. BURGESS. The gentlelady is recognized. 

Ms. MATSUI. Thank you very much, Mr. Chairman, and thank 

you, Mr. Green, for yielding. I thank both of the witnesses here 

today, Dr. Guralnick and Dr. Schutze, for your testimony. Dr. 

Guralnick, you are from UC Davis in my district and thank you 

very much for your work with children and families. 

We are here today to discuss the importance of the Children’s 

Hospital Graduate Medical Education program. As you point out, 

Federal investment in medical education is so important because it 

is very expensive to train doctors and we all benefit from the services that they provide. It is particularly expensive and time-consuming to train those going into specialities. As our pediatricians 

always say, children are not just small adults, and specialized 

training is needed to treat children especially those with complex 

needs. 

With growing student loan debt it is getting harder and harder 

to lure qualified individuals into fields like this so we need to keep 

it up. I look forward to hearing from the witnesses about the importance of the Children’s Hospital GME program and to work with 

my colleagues to reauthorize it. Thank you and I yield back to Mr. 

Green. 

Mr. GREEN. Mr. Chairman, I yield back my time. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. Pending the arrival of the Chairman of the Full Committee, the Chair will now recognize the Ranking Member of the 

Full Committee, Mr. Pallone of New Jersey, 5 minutes for an opening statement, please. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. Every parent understands how stressful it can be when your child gets sick and how 

important it is to have a trusted provider to turn to in these moments. And that is why it is critical that we continue to invest in 

the Children’s Hospital Graduate Medical Education program. 

Over the years, Children’s Hospital GME has helped to build a 

more robust pediatric workforce so that children across the country 

have access to quality care for the most common to the most severe 

health conditions. And currently, more than half of pediatric specialists and close to half of all general pediatricians trained are 

7 

supported by Children’s Hospital GME funds. In addition to the 

training, CHGME funds help to enhance hospitals’ research capabilities so that we can develop new cures and treatments for some 

of the terrible diseases afflicting kids today, and CHGME hospitals 

also play an important role in providing care to vulnerable and underserved children. 

While this program has helped us reverse declines in our pediatric workforce, we know that some areas of the country still face 

shortages of pediatric providers, mainly pediatric subspecialists. 

These shortages severely impact care and lead to longer waits and 

a time-significant travel for children seeking care. And pediatric 

specialists care for some of the sickest children in the nation and 

help them live longer, healthier lives. We need to do all we can to 

make sure every community has adequate access to these specialized providers. 

And CHGME has long been a priority of mine. I was pleased to 

lead the last reauthorization of the program with former Health 

Subcommittee chairman Joe Pitts. The last reauthorization made 

some important changes to the program that have since allowed 

new hospitals to receive the Children’s Hospital GME funds. It also 

allowed for HRSA to create a quality bonus system for the program 

and I look forward to the agency’s continued implementation of 

that system. 

I want to thank Ranking Member Green and Chairman Burgess 

for introducing bipartisan and bicameral legislation to reauthorize 

this vital program. Their bill, H.R. 5385, would reauthorize the 

program for another 5 years and allow for the program to support 

even more residents than it currently does. I am hopeful that we 

will move this legislation through our committee in the near future 

so that we can provide certainty to hospitals that are doing this 

much needed training. And with that I want to thank the witnesses and look forward to your testimony. 

I don’t know if anybody else wants my time. I will yield to the 

gentlewoman from Illinois. 

[The prepared statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Every parent understands how stressful it can be when your child gets sick and 

how important it is to have a trusted provider to turn to in those moments. That’s 

why it’s critical that we continue to invest in the Children’s Hospital Graduate Medical Education (CHGME) program. Over the years, CHGME has helped to build a 

more robust pediatric workforce so that children across the country have access to 

quality care for the most common to the most severe health conditions. 

Currently more than half of pediatric specialists and close to half of all general 

pediatricians trained are supported by CHGME funds. In addition to training, 

CHGME funds help to enhance hospitals’ research capabilities so that we can develop new cures and treatments for some of the terrible diseases afflicting kids 

today. CHGME hospitals also play an important role in providing care to vulnerable 

and underserved children. 

While this program has helped us reverse declines in our pediatric workforce, we 

know that some areas of the country still face shortages of pediatric providers; 

mainly pediatric subspecialists. These shortages severely impact care and lead to 

longer waits and at times significant travel for children seeking care. Pediatric specialists care for some of the sickest children in the nation and help them live longer, 

healthier lives-we need to do all we can to make sure every community has adequate access to these specialized providers. 

CHGME has long been a priority of mine. I was pleased to lead the last reauthorization of the CHGME program with former Health Subcommittee Chairman Joe 

8 

Pitts. The last reauthorization made some important changes to the program that 

have since allowed new hospitals to receive CHGME funds. It also allowed for 

HRSA to create a quality bonus system for the program and I look forward to the 

agency’s continued implementation of that system. 

I’d like to thank Ranking Member Green and Chairman Burgess for introducing 

bipartisan, bicameral legislation to reauthorize this vital program. H.R. 5385 would 

reauthorize the program for another 5 years and allow for the program to support 

even more residents than it currently does. I’m hopeful that we will move this legislation through our Committee in the near future so that we can provide certainty 

to hospitals that are doing this much needed training. 

Thank you to the witnesses for joining us today, I look forward to your testimony. 

I yield the balance of my time. 

Ms. SCHAKOWSKY. I thank the gentleman for yielding. I just 

wanted to say how pleased I am that we are here considering this 

bipartisan legislation. I am proud to be a co-sponsor of H.R. 5385, 

the Children’s Hospital GME Support Reauthorization Act. We 

must ensure that we have a strong health workforce because it is 

the backbone of our healthcare system. Whether it is bolstering the 

pediatric workforce as we are doing today or building our geriatric 

workforce as we do in H.R. 3713, which is also a bipartisan geriatric workforce and caregiver enhancement act I introduced along 

with Representative Doris Matsui and Representative McKinley, it 

is critical that we have the necessary medical infrastructure. It is 

clear that the Children’s Hospital GME programs have been incredibly effective. 

And I yield back unless someone else wants your time. OK, 

thank you. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair will hold the time for the chairman of the 

full committee pending his arrival, but otherwise we will conclude 

with member opening statements. And the chair would like to remind members that pursuant to committee rules all members’ 

opening statements will be made part of the record. 

And we do want to thank our witnesses for being here today and 

taking the time to testify with us before the subcommittee. Each 

witness will have an opportunity to give an opening statement and 

this then will be followed by questions from members. 

Our first panel today, or our only panel today, we will hear from 

Dr. Gordon Schutze, Professor of Pediatrics at Baylor College of 

Medicine, the Executive Vice President and Chief Medical Officer 

of Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital; and, Dr. Susan Guralnick, Associate Dean for 

Graduate Medical Education, University of California, Davis. 

Again, we appreciate you being here with us today. 

Dr. Schutze, you are recognized for 5 minutes for your opening 

statement, please. 

9 

STATEMENTS OF GORDON E. SCHUTZE, M.D., PROFESSOR OF 

PEDIATRICS, EXECUTIVE VICE PRESIDENT AND CHIEF MEDICAL OFFICER, BAYLOR INTERNATIONAL PEDIATRIC AIDS 

INITIATIVE, TEXAS CHILDREN’S HOSPITAL; AND, SUSAN 

GURALNICK, M.D., ASSOCIATE DEAN FOR GRADUATE MEDICAL EDUCATION, UNIVERSITY OF CALIFORNIA, DAVIS 

STATEMENT OF GORDON SCHUTZE 

Dr. SCHUTZE. Chairman Burgess, Ranking Member Green, and 

members—— 

Mr. BURGESS. This is the premier technology committee of the 

United States House of Representatives. 

Dr. SCHUTZE. All right. 

Mr. BURGESS. Thank you. Very good. 

Dr. SCHUTZE. Chairman Burgess, Ranking Member Green, and 

members of the subcommittee, thank you for the opportunity to testify in support of H.R. 5385. I am Dr. Gordon Schutze. I currently 

serve as Executive Vice Chair of the Department of Pediatrics at 

the Baylor College of Medicine at Texas Children’s Hospital in 

Houston, Texas. 

I appreciate the opportunity to come before you to represent 

Texas Children’s Hospital and the 220 other members of the Children’s Hospital Association, all of whom support this important legislation that is critical to the future of children’s health in our nation. First, I want to thank the subcommittee for your historic support of this program, especially our Texas members, Chairman 

Burgess and Ranking Member Green, for introducing this bipartisan legislation to reauthorize and strengthen the support for 

CHGME, a vital program to our nation’s children’s hospitals. 

I graduated from the Texas Tech School of Medicine. I did my 

residency training in pediatrics followed by subspecialty training in 

infectious disease at Baylor College of Medicine and Texas Children’s Hospital. I currently manage the growth and direction of our 

graduate medical education training programs, and with this in 

mind I am pleased to be here with you this afternoon to provide 

you with the insight on this importance of CHGME. 

Baylor’s Department of Pediatrics is the largest department of 

pediatrics in the United States with over 1,300 faculty members, 

all of whom are on staff at Texas Children’s Hospital. Along with 

voluntary faculty from the community, these faculty and staff train 

over 1,100 residents and fellows at our hospital, making it the largest pediatric residency training program in the country. 

GME learners rotate through affiliated hospitals and programs 

in Houston and around the world. Of the residents that work for 

us, 410 are recognized CHGME slots of which 216 are residents in 

training and the remaining 194 are considered fellows or subspecialty residents. Of these, only 165 are eligible for CHGME 

funding per rules which limits the number of new physicians our 

program can consider for funding. 

Having one of the largest training programs also results in significant expense. Our CHGME costs for the program for 2017 

amounted to $42.7 million of which $10.9 million were funded 

through CHGME support. Thus, only about 25 percent of our program costs are covered by CHGME dollars. The remaining exVerDate Nov 24 2008 09:58 Jan 17, 2019 Jkt 037690 PO 00000 Frm 00015 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-135 CHRIS
10 

penses are paid by Texas Children’s Hospital. Besides the financial 

commitment, children’s hospitals also have to guarantee funds for 

the entirety of a resident’s training over 3 years or more, train our 

post-graduate learners on issues surrounding patient safety, and 

most importantly, children’s hospitals are committed to diversity in 

the workforce. We recruit and train doctors that look and sound 

like the patients and families that we serve. 

Children’s hospitals serve as a majority safety net provider with 

more than half of their care devoted to children in the Medicaid 

and CHIP programs. Through what I think is an innovative program called Project DOC, providers are sent to the homes of children with complex medical conditions to learn from their parents 

what it is like to care for chronically ill or a medically complex 

child. 

In pediatrics, unlike in adult residency programs, residents and 

fellows are trained early on that they will be serving no less than 

two people when caring for a child, meaning they must be taught 

how to communicate with the patient and his or her caregiver not 

only in how they assess a patient’s medical history, but also how 

they will conduct the exams, easing the anxiety of the child as well 

as the family unit. Because children’s hospitals see the sickest of 

the sick, our training programs train pediatric specialists in complex care and behavioral health creating pediatricians who have an 

expertise in both of these emerging health issues. 

The children’s hospitals of this nation serve as a center for scientific discovery focused solely on kids. They provide lifesaving 

clinical research that is a direct result of their strong academic programs which are inextricably tied to support by CHGME. CHA 

data provides support for a strong correlation between physician 

shortages and access to pediatric care for America’s children. 

Nationally, workforce shortages exist in critical subspecialties as 

mentioned here earlier such as pediatric neurology, developmental 

and behavioral pediatrics, child and adolescent psychiatry, and others. Meanwhile, as the national population of children continues to 

grow so does the growth of children with chronic and complex medical conditions. It is essential that we work to continue to train this 

workforce and seek to attract physicians to these areas of high 

need. CHGME support will help us continue to address these workforce gaps and increase access to vital specialized services. 

In closing, CHGME is a sound investment in the future of our 

nation’s children. CHGME helps to ensure a stable future for our 

nation’s children’s hospitals and its pediatric workforce. I respectfully ask for your support of H.R. 5385 and the requested funding 

of $330 million. Thank you for this opportunity to share my professional insight. I respectfully ask that my written testimony be submitted for the record, and I am happy to answer any questions at 

this time. 

[The prepared statement of Dr. Schutze follows:] 

11 


33535.001

~ 

~ Texas Children's 

Hospital" 

Testimony of Gordon E. Schulze, M.D., F.A.A.P. 

Executive Vice Chairman, Department of Pediatrics, Baylor College of Medicine 

Before the House Committee on Energy and Commerce Subcommittee on Health 

"Reauthorization of the Children's Hospital Graduate Medical Education Program" 

May 23, 2018 

Chairman Burgess, Ranking Member Green, and members of the Subcommittee, thank you for 

the opportunity to speak in support of H.R. 5385, "The Children's Hospital GME Support Reauthorization 

Act of 2018." I am Dr. Gordon E. Schulze, a professor of pediatrics and executive vice chairman of the 

department of pediatrics at Baylor College of Medicine and Texas Children's Hospital. In addition, I am 

the holder of the Martin I. Lorin, M.D. endowed chair in medical education and serve as the Baylor 

International Pediatric Aids Initiatives executive vice president as well. Over the past years, I have served 

as a general pediatric residency program director, as well as a program director for pediatric infectious 

diseases subspecialty training program, and a Pediatric Global Health residency program. I am 

appearing today on behalf of Texas Children's Hospital and the 220 nationwide members of the 

Children's Hospital Association. 

I wish to thank the Subcommittee for its long history of supj)Ort for the Children's Hospitals 

Graduate Medical Education Program (CHGME) and for children's health. I also want to specifically 

thank Rep. Green and Rep. Burgess for introducing this bipartisan legislation which would reauthorize 

the CHGME program for five years and strengthen vital pediatric training programs. 

The CHGME program represents our nation's most significant investment in strengthening the 

pediatric workforce. CHGME was created in 1999 with bipartisan support because Congress recognized 

that a dedicated source of funding for training the next generation of pediatricians and pediatric specialists 

in children's hospitals was needed. Prior to the establishment of the CHGME program, children's 

hospitals were effectively left out of the federal GME system of support provided through Medicare, 
12 


33535.002

because we treat children, mostly through Medicaid and the Children's Health Insurance Program. 

Unfortunately, the average CHGME payment per full-time equivalent (FTE) resident represents 

approximately half of what Medicare GME provides to support training at general acute care hospitals. 

Since the establishment of the program, CHGME funding has enabled children's hospitals to 

dramatically increase training overall, and in particular grow the supply of pediatric specialists- the area 

of greatest shortage in children's health care. Today, only 1 percent of all hospitals in the United States 

- that is 58 children's hospitals - are eligible to receive CHGME -Yet, these institutions train 

approximately half of the nation's pediatricians, more than 7,000 FTEs annually -including 44 percent 

of all general pediatricians and 57 percent of all pediatric specialists. 

Between 2000 and 2015, CHGME-supported hospitals collectively increased the number of 

residents trained by 113 percent. Over the same time frame, CHGME hospitals also increased the 

number of pediatric subspecialists they train by 206 percent. Today, in the majority of pediatric 

subspecialist fields tracked by the American Medical Association, more than 65 percent of residents are 

trained at CHGME hospitals and in some fields, such as pediatric rehabilitation medicine, virtually all 

physicians receive their training at CHGME hospitals' 

H.R. 5385 strengthens our nation's commitment to bolster the pediatric workforce today and into 

the future by supporting the training of doctors who care for children living in every state- in cities, rural 

communities, suburbs and everywhere in between. My own hospital, Texas Children's Hospital, is the 

academic home for the Department of Pediatrics at the Baylor College of Medicine, and we serve as the 

principal training site for the Medical College's pediatric residency program, pediatric fellowship 

programs, and medical student pediatric education. The department is one of the largest, if not the 

largest, academic pediatric department in the United States, with over 1,300 faculty members. 

While our primary academic partner is Baylor College of Medicine, we also train physicians from 

University of Texas Health Science Center at Houston, Methodist, and University of Texas Health 

6621 Fannin St. I Houston, TX 77030 

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Science Center at Houston School of Dentistry. CHGME funding supports the provision of their curriculum 

under the expertise of a highly qualified faculty with a diverse population of patients and health needs. 

In fiscal year 2017, the cost of training these residents and fellows amounted to $42.7 million, of 

which approximately 25 percent of the cost was subsidized with CHGME funding. This Health Research 

and Services Administration (HRSA) dollars totaled approximately $10.9 million. 

To further illustrate the size and scope of our medical education training program below is an 

outline of what Children's Hospital Graduate Medical Education funds support within Texas Children's 

Hospital and our teaching partners: 

Texas Children's Hospital has 1,153 people training in our hospital GME programs 

amounting to 426 Full Time Equivalents (FTEs). 

216 of these FTEs are pediatric residents and 194 are pediatric fellows. 

None of this would be possible without CHGME. Furthermore, there are no adequate substitutes 

for CHGME to support training at eligible children's hospitals. Other potential sources of support, such 

as Medicaid GME or grant funding, are not available to many children's hospitals and cannot support 

training on the scale necessary to meet current and future workforce needs. The Children's Hospital GME 

Support Reauthorization Act of 2018 would help address this funding shortfall by increasing the 

authorization level for CHGME to $330 million a year. 

However, much remains to be done to continue to expand access to care for our America's 

children. Nationally, workforce shortages persist, most acutely among pediatric subspecialties, such as 

developmental pediatrics, child and adolescent psychiatry, and pediatric genetics and genomics. Many 

hospitals struggle to fill vacancies for these types of providers and in other areas, wait times can exceed 

two or three months. CHA survey data shows, for example, average wait times of 18.7 weeks for 

developmental pediatrics and 9. 9 weeks for child and adolescent psychiatry. " In certain areas of the 

country, localized shortages in pediatric primary care also persist. 

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The national population of children is predicted to continue at a growth rate of 3 percent through 

2030. At the same time, the health care needs of the pediatric population are increasing as the number 

of children with complex medical conditions is growing at a faster rate than the overall child population, 

requiring an increasing number of specialty care providers.'" 

CHGME has an indisputable track record of success. Thanks to CHGME, children's hospitals 

have developed training programs in highly specialized disciplines that target the unique needs of 

children with complex medical conditions- examples include pediatric surgical oncology, radiation 

oncology, pediatric pathology and bone marrow transplantation. For some of these disciplines, only a 

small number of institutions provide training. Reauthorizing CHGME will help children's hospitals 

continue to address these workforce gaps and increase access to these vital specialized services. 

CHGME is operated in a data-driven and transparent manner. The Health Resources and 

Services Administration (HRSA), which administers the program, collects information on program 

outcomes and uses these performance measures for ongoing evaluations. Children's hospitals that 

receive CHGME support are required to annually report data to HRSA on: 

1. Types of residency training programs, such as general pediatrics, internal medicine/pediatrics, 

and pediatric specialties 

2. Number of training positions for residents, 

3. Types of training provided for residents related to the health care needs of different populations, 

such as children underserved for reasons of family income or geographic location 

4. Changes in residency training , including changes in curricula and training experiences, and 

changes for the purpose of training residents in the measurement, improvement, quality and 

safety of patient care 

In addition, HRSA is authorized to implement a quality bonus system for the CHGME program, which it 

plans to do by fiscal year 2019. 

Reauthorizing the CHGME program is a vital step forward in helping children achieve their full health 

potentiaL Through its passage, Congress is helping ensure graduate medical education programs that 

will have the resources and talent to care for the next generation of software engineers, entrepreneurs, 

professional dancers, Olympic athletes, teachers, and caregivers. In summary, the CHGME program is 

critical to protecting gains in pediatric health and ensuring access to care for children nationwide. On 

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33535.005

behalf of Texas Children's Hospital, the Children's Hospital Association and the children and families we 

serve, thank you for your support for this critical program. A robust pediatric workforce is essential to 

ensuring that no child lacks access to high-quality medical care. Please advance H.R. 5385, The 

Children's Hospital GME Support Reauthorization Act of 2018. 

Respectfully submitted, 

Gordon E. Schulze, M.D., F.A.A.P. 

Professor of Pediatrics 

Executive Vice Chairman 

Martin I. Lorin, M.D., Endowed Chair in Medical Education 

Department of Pediatrics 

Baylor College of Medicine 

Executive Vice President and Chief Medical Officer 

Baylor International Pediatric AIDS Initiative 

at Texas Children's Hospital 

; ~'Percentage of Pediatric Specialists Trained at CHGME Recipient Hospitals" Children's Hospital Association fact sheet. 

issued April, 2018. 

---'-""'"""-"-"=='-""-="""""'"-"'"-"'""-'Children's Hospital Association fact sheet, issued January, 2018. 

"Summary of Available Evidence and Methodology for Determining Potential Medicaid Savings from Improving Care 

Coordination for Medically Complex Children," p. vi, prepared for Children's Hospital Association by Dobson DaVanzo & 

Associates, issued October 2013. 

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SIPage 
16 

Mr. BURGESS. Thank you, Dr. Schutze, and your written statement of course will be part of the record. 

Dr. Guralnick, you are recognized for 5 minutes for an opening 

statement, please. 

STATEMENT OF SARAH GURALNICK 

Dr. GURALNICK. Chairman Burgess, Ranking Member Green, and 

members of the subcommittee, thank you for holding this hearing 

on legislation that is critical to the training of the next generation 

of providers of medical care to children. My name is Dr. Susan 

Guralnick and I am a Pediatrician with over 30 years in clinical 

practice. I am currently the Associate Dean for Graduate Medical 

Education at UC Davis Health, but I am here today in an official 

capacity representing the American Academy of Pediatrics, AAP, 

and its committee on pediatric education which I chair. 

The AAP is a nonprofit professional organization of over 66,000 

primary care pediatricians, pediatric medical subspecialists, and 

pediatric surgical specialists. The American Academy of Pediatrics 

strongly supports H.R. 5385, the Children’s Hospital GME Support 

Reauthorization Act of 2018. We particularly want to thank Chairman Burgess and Ranking Member Green for sponsoring this important legislation. 

Children are not just little adults. They require medical care that 

is appropriate for their unique needs. Pediatricians, a term that includes primary pediatricians, pediatric medical subspecialists, and 

pediatric surgical specialists are physicians who are concerned primarily with the health, welfare, and development of children and 

are uniquely qualified to care for children by virtue of this interest 

and their initial training. 

Training to become a pediatrician generally includes 4 years of 

medical school followed by residency training of at least 3 years of 

hands-on intensive graduate medical education or GME training 

devoted solely to all aspects of medical care for children, adolescents, and young adults. All told, training to become a primary care 

pediatrician consists of approximately 12- to 14,000 clinical hours. 

After residency, pediatricians may elect to complete fellowship 

training of usually at least another 3 years to become a pediatric 

medical subspecialist. The training required of a pediatric medical 

subspecialist prepares them to take care of children with serious 

diseases and other specialized healthcare needs. Examples include 

neonatologists who take care of babies born experiencing withdrawal from in utero opioid exposure, pediatric endocrinologists 

who address child obesity and diabetes, and pediatric oncologists 

who treat children with brain cancer. When children require surgery, specialized pediatric surgeons offer specialized surgical skills 

for children. Pediatric surgical specialists begin their medical training in general surgery but must also complete fellowship training 

in their desired pediatric surgical specialty. 

Safe and high quality care of children requires specialized training. In addition to a general knowledge of diseases, pediatric specialists must know and understand the various ways that diseases 

present and are managed with consideration of the age of the child. 

As children grow, their risk of each illness changes as does its 

management. The pediatric specialist must continuously monitor 

17 

and address each child’s growth, development, and behavior. Pediatric specialists also must be trained in appropriate interaction and 

shared decisionmaking with parents. 

As a result of advances in medical care, the United States has 

greatly increased the survival of children. These children require 

specialist physicians with expertise in complex and specialty care 

to meet their needs. Training physicians to provide optimal health 

care for children requires substantial investments of time, effort, 

and resources. The Federal Government investment in medical 

training is essential in making this happen. GME funding benefits 

everyone. It is a costly endeavor but it is essential to ensuring that 

America’s physicians are trained and in sufficient supply to be able 

to tackle the complicated health challenges we face as a nation. 

While Medicare is the largest source of GME funding, the Children’s Hospital Graduate Medical Education, CHGME, program is 

an essential funding component for hospitals that do not receive 

Medicare GME support. In fact, hospitals that receive CHGME 

funding train approximately half of all primary care and subspecialty pediatricians in the United States, making the program 

indispensable for maintaining the pipeline of physicians trained to 

take care of children. 

At my institution the hospital receives Medicare GME because 

we are integrated into an adult system that receives this funding 

which helps finance our pediatric training programs as well. However, freestanding children’s hospitals without such institutional affiliations do not qualify for this Medicare funding. Prior to the 

CHGME program these hospitals were unable to directly utilize 

Federal GME funding. CHGME is therefore an essential tool in 

continuing to address the inequities in training funding for hospitals solely focused on the care of children. 

Pediatrics is facing a significant shortage of medical and surgical 

subspecialists. We are not training enough subspecialists to keep 

up with the increasing needs among children especially those with 

special healthcare needs. Unfortunately, these shortages impact patient care. Wait times to see pediatric subspecialists are unacceptably high among many specialties and families often need to travel 

long distances, many times to another state to see the appropriate 

specialists. Simply put, children should not have to get on an airplane to see their doctor. 

Renewing CHGME is a first step, but training funding alone will 

not sufficiently address these shortages. There are also personal financial drivers including high student debt load that make pediatricians think twice before deciding to further specialize. We must 

address these negative incentives. We also urge this committee to 

look seriously at legislation that would offer loan repayment for pediatric subspecialists. 

Thank you for the opportunity to share our thoughts with you 

today and I welcome any questions you have. 

[The prepared statement of Dr. Guralnick follows:] 

18 


33535.006

Testimony of 

Susan Guralnick, MD, FAAP 

Chair, Committee on Pediatric Education 

American Academy of Pediatrics 

Before the 

Subcommittee on Health 

Committee on Energy and Commerce 

U.S. House of Representatives 

"Reauthorization of the Children's Hospital 

Graduate Medical Education Program" 

May 23,2018 

American Academy of Pediatrics 

DEDICATED TO THE HEALTH OF ALL CHILDREN'" 
19 


33535.007

Chairman Burgess, Ranking Member Green, and members of the subcommittee, thank you for holding 

this hearing on legislation that is critical to training the next generation of providers of medical care to 

children. My name is Dr. Susan Guralnick, and I am a pediatrician with over 30 years in clinical practice. I 

am a primary care pediatrician that specializes in the care of children with special health care needs. 

Throughout my career, I have made medical education a central focus of my work. I am currently a 

Professor of Pediatrics and the Associate Dean for Graduate Medical Education at UC Davis Health. But I 

am here today in an official capacity representing the American Academy of Pediatrics (AAP) and its 

Committee on Pediatric Education, which I chair. The AAP is a non-profit professional organization of 

over 66,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists 

dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. 

The American Academy of Pediatrics strongly supports H.R. 5385, the Children's Hospital GME Support 

Reauthorization Act of 2018, and appreciates the opportunity to share our views with the subcommittee 

today. We particularly want to thank Chairman Burgess and Ranking Member Green for sponsoring this 

important legislation. 

The Importance of Pediatric Graduate Medical Education 

Children are not just little adults; they require medical care that is appropriate for their unique needs. 

Pediatricians, a term that includes primary care pediatricians, pediatric medical subspecialists, and 

pediatric surgical specialists, are physicians who are concerned primarily with the health, welfare, and 

development of children and are uniquely qualified to care for children by virtue of this interest and 

their initial training. 

Training to become a pediatrician generally includes 4 years of medical school education, followed by 

residency training of at least 3 years of "hands on," intensive medical training devoted solely to all 

aspects of medical care for children, adolescents, and young adults. All told, this training to become a 

primary care pediatrician consists of approximately 12,000 to 14,000 hours of clinical training. 

After board certification in general pediatrics, pediatricians may elect to complete fellowship trainingof usually at least another 3 years-to become a pediatric medical subspecialist. The training required of 

pediatric medical subspecialists prepares them to take care of children with serious diseases and other 

specialized health care needs. Examples include neonatologists who take care of babies born 

experiencing withdrawal from in utero opioid exposure, pediatric endocrinologists who address child 

obesity and diabetes, and pediatric hematologists/oncologists who treat children with brain cancer. 

When children require surgery, specialized pediatric surgeons offer specialized surgical skills for 

children. Pediatric surgical specialists begin their medical training in general surgery but must also 

complete fellowship training in their desired pediatric surgical specialty. 

Safe and high quality care of children requires specialized training. In addition to a general knowledge of 

diseases, pediatric specialists must know and understand the various ways that diseases present and are 

managed with consideration of the age of the child. As children grow, their risk of each illness changes, 

as does its management. The pediatric specialist must continuously monitor and address each child's 

growth and development, as well as behavioral issues. Pediatric specialists must also be trained in the 

care of not just children, but appropriate interaction and shared-decision making with parents, family 

Page 2 
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33535.008

members, and other guardians. As a result of advances in medical care, the United States has greatly 

increased the survival of children in general, including those with special health care needs. These 

children require specialist physicians with expertise in complex and specialty care to meet their 

healthcare needs. 

Training physicians to provide optimal health care for children requires substantial investments of time, 

effort, and resources. The federal government investment in medical training is essential in making this 

happen. Federal funding of graduate medical education benefits everyone. Medical training is a costly 

endeavor, but is one that is essential to ensuring that America's physicians are trained-and in sufficient 

supply-to be able to tackle the complicated health challenges we face as a nation. Teaching hospitals 

also provide 37% of all charity care in the United States, making medical training, or graduate medical 

education (GME}, programs essential in expanding access to uninsured and underserved populations. 

While Medicare is the largest source of GME funding, the Children's Hospital Graduate Medical 

Education (CHGME) program is an essential funding component for hospitals that do not receive 

Medicare GME support. In fact, hospitals that receive CHGME funding train approximately half of all 

primary care and subspecialty pediatricians in the United States, making the CHGME program 

indispensable for maintaining the pipeline of physicians trained to take care of children. 

At my institution, the hospital receives Medicare GME because we are integrated into an adult system 

that receives this funding, which helps finance our pediatric training programs as well. However, 

freestanding children's hospitals, without such institutional affiliations, do not qualify for this Medicare 

funding. Prior to the CHGME program, these hospitals were unable to directly utilize federal GME 

funding. CHGME is, therefore, an essential tool in continuing to address the inequities in training funding 

for hospitals solely focused on the care of children. 

Critical Shortages in Pediatric Subspecialty Care 

Pediatrics is facing a significant shortage of medical and surgical subspecialists. We are not training 

enough subspecialists to keep up with the increasing needs among children, especially those with 

special health care needs. Unfortunately, these shortages severely impact patient care. Primary care 

pediatricians report having difficulty locating trained subspecialists to whom they can refer their 

patients. Wait times to see pediatric subspecialists are unacceptably high among many specialties, and 

families often need to travel long distances (many times to another state) to see the appropriate 

specialists. Simply put, children should not have to get on an airplane to see their doctor. We must do 

more to address these shortages. Ultimately, we hope to work with Congress to raise the caps on the 

number of GME slots and to ensure that both pediatric primary care and pediatric subspecialty training 

are fully funded. 

However, training funding alone will not sufficiently address these shortages. There are also personal 

financial drivers, including high student debt load, that make pediatricians think twice before deciding to 

further specialize. After completing their primary care residencies, pediatricians often have an economic 

incentive to immediately enter clinical practice and draw a salary rather than to embark on subspecialty 

training that may paradoxically result in lower lifetime earnings compared to primary care pediatrics. 

We must do more to address these negative incentives. Solutions include offering loan repayment for 

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33535.009

pediatric subspecialists and improving Medicaid provider payment rates which are unacceptably low 

compared to Medicare. 

The Future of Graduate Medical Education Funding 

Ensuring that the authorization for the CHGME program is extended beyond its current expiration at the 

end of September is the urgent priority currently before Congress. However, we ask the subcommittee 

to also think long-term about ensuring that federal GME policy is optimally suited to ensure quality, 

stable funding for pediatric medical education. CHGME still offers substantially less funding than 

Medicare GME on a per resident basis. Public funding of GME should not value medical training for 

children any less than medical care for adults. The health care of children is no less complex. We call on 

Congress to remedy this inequity. 

Additionally, while Medicare GME is a mandatory funding stream, CHGME is a discretionary program 

that not only requires Congress to reauthorize it every five year, but also requires pediatric advocates to 

advocate for funding every year in the appropriations process. We urge Congress to enact a stable and 

predictable funding mechanism for pediatric GME. 

The AAP looks forward to working with the subcommittee to ensure quick passage of the Children's 

Hospital GME Support Reauthorization Act of 2018. Thank you for the opportunity to share our thoughts 

with you today. 

Page 4 
22 

Mr. BURGESS. Thank you, Dr. Guralnick. We appreciate both of 

you being here today. We will move to the question portion of the 

hearing. We will have a series of votes in probably 15 or 20 minutes. For that reason I am going to go down the dais and recognize 

Billy Long from Missouri, 5 minutes for questions, please. 

Mr. UPTON. Will the gentleman yield just for a second while he 

gets his thoughts together? 

Mr. LONG. Sure. 

Mr. UPTON. I just want to say we really appreciate you being 

here. I was on the super committee. It was a bipartisan, bicameral 

committee a few years ago and there was a serious effort to go 

after GME, not only after kids, but the whole program. And you 

will be pleased to know that Rob Portman and Dave Camp and I 

were the ones that really put the skids to that. 

I visited Texas a number of times. I have seen the work. I have 

great schools in Michigan as well, but all around the country we 

travel and get testimony from you folks. I had a number of physician, related fields, in my office yesterday and again this week a 

number of different times. We just really appreciate your testimony. This is an important bill that we need to move forward. And 

particularly now that we have a budget agreement, something that 

the President signed with bipartisan support in both the House 

and the Senate, I have got to believe that we aren’t going to be 

worried with threats coming after GME. 

So I have a new medical school in my district, Kalamazoo, Western Michigan University. I was there on Saturday for a huge event. 

This is critical if we are going to train the folks to be back. I just 

want to say thanks, and I yield to my good friend, Mr. Long. 

Mr. LONG. Thank you. And as a parent of a newly minted pediatrician I appreciate you all being here today. My daughter finishes 

up June 30th her third-year residency and will start practicing 

very shortly after that. 

Dr. Guralnick, in your testimony you focus on the shortages in 

pediatric subspecialty care. Could you discuss how the shortages 

are impacting patient care? 

Dr. GURALNICK. Thank you for that question. There is a significant impact in many areas. One of the difficulties is having the 

funding to encourage people to do these specialities, to take the 

time. They often don’t have enough, it affects their earnings to 

choose to do these specialties, and without enough specialists—we 

have states that don’t have, or have one subspecialist in any particular area. There are lots of parts of the country where people 

have to go hundreds of miles to reach somebody. 

And say, for example, you have a child with diabetes or you have 

a child with epilepsy. They can’t necessarily access specialists in 

their area to take appropriate care of them. 

Mr. LONG. You mentioned or you noted in your testimony and 

mentioned here that pediatricians face negative incentives to further specialize in care. Could you expand on what these issues are 

and how they disincentivize pediatricians from further specialization? 

Dr. GURALNICK. One of the interesting things to me is that there 

is, it is counter intuitive in that generally a subspecialist would 

earn a higher salary than a generalist. But the money that they 

23 

lose over the time that they train to become a subspecialist when 

they could have been in primary care practice ends up costing them 

more than it gains them to become a subspecialist. Also over that 

time they gain interest in many of the loans that they have been 

building up so that they go further into debt over the years that 

they are subspecialty training. 

Mr. LONG. I am the sponsor of the Ensuring Children’s Access to 

Specialty Care Act which would allow pediatric subspecialists practicing in underserved areas to participate in the National Health 

Service Corps loan repayment program. Could you discuss the importance of loan repayment programs in addressing the shortages 

of these pediatric subspecialists? 

Dr. GURALNICK. Yes, thank you for your leadership on that issue. 

That is a very important issue. Right now the National Health 

Service Corps is very helpful in getting primary care doctors into 

underserved areas, but because subspecialists cannot get the loan 

help with that with the loan repayment we don’t get the people 

going into subspecialties who need to get that loan repayment 

through that service, as well as if we have people who are subspecialists placed in those underserved areas it greatly impacts the 

care of children in areas where we have no subspecialists at this 

time. 

Mr. LONG. And what else can we do to address these negative incentives to narrow that gap in these subspecialties? 

Dr. GURALNICK. Well, one of them is the incentives for the trainees, as I mentioned. One of the other negative incentives is for hospitals because fellowships right now through funding only get 50 

percent of what residents receive to get their training. So hospitals 

are disincentivized to have many fellows there because they have 

to pay a great portion of the salary and support of those trainees. 

Mr. LONG. OK, thank you. 

And Dr. Schutze, in your testimony you talk about how the number of children with complex medical conditions is growing at a 

faster rate than the overall child population, but workforce shortages persist more acutely among pediatrician subspecialties. How 

can we address these workforce gaps and increase access to these 

vital specialized services? 

Dr. SCHUTZE. I think giving exposure to residents and learners 

early on about complex medical issues and how to take care of 

them. I think general pediatricians as a rule sometimes don’t get 

exposed to many of these and I think the more exposure they have 

in training, the more comfortable they are with them, the more 

comfortable they will be taking care of these people and these kids 

when they get out. 

Also that will help because of the shortages in some subspecialties if we can make the general pediatrician more comfortable with 

these complex patients then there will be less of a need to require 

total subspecialty care by these patients. 

Mr. LONG. OK. 

Dr. SCHUTZE. It is a win-win for everybody. 

Mr. BUCSHON. Can you give me your 20 seconds? 

Mr. LONG. I yield 22 seconds. 

Mr. BURGESS. The chair rejoices. The chair thanks the gentleman. 

24 

Mr. BUCSHON. He yielded 20 seconds to me. 

Mr. BURGESS. Oh, oh. He yielded to you. Oh my gosh. 

Mr. BUCSHON. I will be brief. 

Mr. LONG. Actually he grabbed my microphone. 

Mr. BUCSHON. I did, yes. I was a heart surgeon before I was in 

Congress and I just want to say this. The debt that kids are coming 

out of medical school I firmly believe is impacting their career 

choices and, historically, as you know pediatricians have been on 

the lower end of the salary scale of medical specialists. And I am 

being presumptuous here, but I am just making the assessment 

that it likely is impacting the ability to recruit pediatricians as well 

as pediatric subspecialists. I yield back to Billy Long. 

Mr. LONG. And I yield back to the chairman. Thank you all again 

very much. I appreciate what you do and your dedication and you 

all being here today. Thank you. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentleman from Texas, Mr. 

Green, 5 minutes for your questions, please. 

Mr. GREEN. Thank you, Mr. Chairman. It is nice to have a fellow 

from Missouri say you all. 

Dr. Schutze, you mentioned in your testimony that your department is one of the largest academic pediatric departments in the 

country and Texas Children’s Hospital has made significant investment in graduate medical education. First of all, I would like to 

thank you. A lot of my district is medically underserved in a very 

urban area and Texas Children’s Hospital has clinics in those areas 

where a lot of our other hospitals do not, so I sure appreciate it. 

Could you discuss how much of your department’s pediatric training is funded through the federal GME programs? Is CHGME the 

largest source of support for Texas Children’s pediatric training 

programs? 

Dr. SCHUTZE. Yes, thank you, Congressman Green. It is the only 

source of funding we have outside of Texas Children’s itself. So the 

hospital itself ponies up the rest of the money, otherwise that is 

the only source of funding outside of the hospital that we have. 

Mr. GREEN. You note in your testimony there is a pediatric workforce shortfall nationwide, especially in pediatric subspecialties 

such as developmental pediatrics, children and adolescent psychiatry, and pediatric genetics. What are the underlying reasons dissuading doctors from specializing in pediatrics? 

Dr. SCHUTZE. Much like what Dr. Guralnick said, some of it is 

financially based, some of these subspecialties get paid less than 

general pediatricians plus the time put in. Some of it is just it 

takes the right person to do some of these specialties. And I think 

in order to have people go into these specialties they have to be exposed to these specialties at a young age. 

Many of the smaller pediatric programs don’t have a 

behavioralist or an adolescent psychiatrist, et cetera, and so the 

larger programs, really, it becomes incumbent upon us to get exposure to young learners early so that they can be exposed to these 

specialties and hopefully pick these specialties to go into. 

Mr. GREEN. How does CHGME help address that challenge? Obviously, it is your only funding. 

25 

Dr. SCHUTZE. Right. It is our only funding, but it gives us the 

ability to bring in residents of all sorts so they can get this type 

of training. It is essential to what we do. 

Mr. GREEN. Will the $30 million increase in annual funding set 

in H.R. 5385, the Children’s Hospital GME Support Reauthorization Act, help address this challenge? 

Dr. SCHUTZE. Absolutely. I think it will help address those challenges in institutions that already get CHGME funding and maybe 

it will allow others that don’t have access to it to have access to 

some as well. 

Mr. GREEN. Dr. Guralnick, is this also the only funding for the 

training at UC Davis, similar to the Texas Children’s? 

Dr. GURALNICK. No, it is not. We are not a freestanding children’s hospital so we get Medicare GME at our institution. 

Mr. GREEN. That was my question about how important is 

CHGME to freestanding hospitals operating graduate medical programs. If that didn’t exist would these programs adequately support the GME at these hospitals? 

Dr. GURALNICK. Without that I think there would be institutions 

that could not support GME at all. They would not be able to have 

the funding to support those programs and certainly a lot of the 

programs would close. 

Mr. GREEN. OK. 

Thank you, Mr. Chairman, and I will yield back my time. 

Mr. BURGESS. The chair thanks the gentleman. We do have a series of votes on the floor so we are going to briefly recess the subcommittee and we will reconvene immediately following the votes 

on the floor. The subcommittee stands in recess. 

[Whereupon, at 1:38 p.m., the subcommittee recessed, to reconvene at 2:35 p.m., the same day.] 

Mr. BURGESS. I will call the subcommittee back to order and recognize myself for 5 minutes for questions. And to the Ranking 

Member, since we have a Texas contingent here today that is pretty solid, Dr. Benjy Brooks was the first woman to become a pediatric surgeon in Texas. She was actually at the Texas Medical Center when I was in medical school down there many years ago. She 

was actually born in the town that I practiced in, Lewisville, Texas, 

and interestingly enough she was born in 1918, so this is her centennial year. 

The reason I bring up her name is because we have had so many 

people today say that children are not just little adults; fair statement. Benjy had kind of a unique way, or Dr. Brooks had a unique 

way of phrasing it. She would get right in your face and say, kids 

are different. So kids are different and I will take her admonition 

now these many years later as we work this. 

I think one of the things, Dr. Schutze and Dr. Guralnick, one of 

the things that I have worked on for a number of years has been 

physician workforce. Not just in the pediatric space but in a larger 

perspective. But talk to us a little bit about the availability of residency slots for people who are graduating medical school. How are 

we doing on that? 

I will start with you, Dr. Schutze, in the State of Texas, and then 

we are interested in California as well. 

26 

Dr. SCHUTZE. That is an interesting question. Thank you for the 

question. As medical schools are increasing to try to increase output of physicians, and certainly even in Texas we now have a 

school in Austin, a school in Valley, U of H may be getting a school 

soon, TCU, Incarnate Word, et cetera. And so what is happening 

is that we are going to certainly produce more physicians in the 

State and in the Nation, but again the number of GME slots hasn’t 

expanded. 

And so, for instance, it used to be that we may see ten percent 

of pediatric trainees coming in may have been from foreign medical 

schools, now that number continues to shrink and at some point in 

the next decade we will probably exceed number of GME spots 

versus the number of graduates we have getting out of medical 

school. 

Mr. BURGESS. And, Dr. Guralnick, for California? 

Dr. GURALNICK. Yes, and I agree with everything Dr. Schutze 

just said. I guess the other important piece is that we aren’t necessarily have, I guess, incentivizing people to go into the specialties 

in the areas that we need. And when we do increase if we get to 

GME slots it would be helpful to have some way of incentivizing 

or encouraging those to be in areas that are underserved and in 

specialties that are underserved. 

Mr. BURGESS. And you of course are talking too about the opportunity costs that are lost with additional time in training in a subspecialty, that although it may pay more than the generalist pediatrician it may not be enough to offset the cost of the opportunity 

cost of going through that additional training. So typically someone 

finishes up almost 4 years of medical school, well, actually it was 

3 years when I went. I was the 3-year wonder kid across the street 

from Baylor. 

But 4 years of medical school, 3 years of general pediatric residency, so now you are 7 years after graduating from college for a 

subspecialty. To be a pediatric cardiologist how long, additionally, 

are we talking about in investment? 

Dr. GURALNICK. A minimum of 3 additional years without any 

further subspecialization. 

Mr. BURGESS. So there is even further subspecialization in the 

field of pediatric cardiology? 

Dr. GURALNICK. There can be. 

Mr. BURGESS. To valvular disease, vessel disease and that sort 

of subspecialization? 

Dr. GURALNICK. There—yes. 

Dr. SCHUTZE. At our institution we have fourth year fellowships 

in heart failure or cardiac imaging or electrophysiology, those kind 

of things. And like in HemOnc we now have a fourth year of fellowship in leukemia or lymphoma, or brain tumor, et cetera. So they 

are adding—— 

Dr. GURALNICK. Congenital heart disease. 

Dr. SCHUTZE. Yes. They are adding these things over and over 

and over. 

Mr. BURGESS. So it is again working on workforce issues over the 

past several years in Texas we have been focused on the fact that 

we are educating more doctors that we can perhaps provide residency slots for, and as you mentioned, Dr. Schutze, that problem 

27 

may even be becoming a little more acute. The concern then is that 

from a physician standpoint we tend to practice where we put 

down roots, which is typically where we do our residency program. 

So referral patterns get established, the comfort with the doctors 

that are also in the community, we frequently will find our significant other and marry at the time of residency, so all of those roots 

get put down. I can remember when we were dealing with the emigration of doctors after Hurricane Katrina and of course DallasFort Worth area was probably as guilty as any from trying to attract the doctors from Charity to come up to the Metroflex and not 

put up with hurricanes in the future. 

And I remember being struck when we were down there for a 

field hearing that it was going to be difficult to hold the physician 

workforce in town and if you didn’t—it is not so much that you 

were from the area, but your spouse needed to be from the New 

Orleans area if you were really likely to stay because just the burden of practice became so difficult under those conditions. 

Well, obviously Mr. Green and I are focused on this as an issue. 

We expect to get this into a markup in the subcommittee and then 

the full committee and we will see what happens from there. I see 

we are joined by the gentleman from Georgia. 

And I recognized you, correct? 

Mr. GREEN. You have, but I will take some more time if you will 

give it to me. 

Mr. BURGESS. I will do that after we recognize Mr. Carter. Oh, 

oh. I beg your pardon. I didn’t see way down in the front row. I 

don’t see as well as I used to. Let me yield 5 minutes to Ms. 

DeGette for questions. 

Ms. DEGETTE. Thank you, Mr. Chairman. I feel like I am at the 

kids’ table down here. 

Mr. CARTER. You will get used to it. 

Ms. DEGETTE. But I am really happy—— 

[Laughter.] 

Ms. DEGETTE. But I am happy I was able to come back because 

this is a really important issue and GME is really, really important. I want to thank both of you for being with us here today. 

As you both may know, Congressman Tom Reed from New York 

and I co-chair the Congressional Diabetes Caucus. As you mentioned in your testimony, Dr. Guralnick, there is already a shortage 

in the primary care pediatric subspecialties and that includes pediatric endocrinologists. I was wondering if you could talk about how 

existing and future shortages of pediatric subspecialists who treat 

chronic conditions like diabetes can impact diabetes management, 

quality of life, and eventually life expectancy. 

Dr. GURALNICK. Certainly. It is very significant, especially children who have type 1 diabetes, which is more common in children, 

and then now we have so much more type 2 diabetes from obesity. 

It is a growing epidemic. There are a lot of complications of diabetes. You can go blind. You can have kidney disease. So it has significant long-term impact on chronic health, chronic illness, and decreases longevity. And if we don’t have subspecialists trained in 

taking care of these children then we are much more likely to have 

these complications unrecognized, untreated, with long-term adult 

negative impact. 

28 

Ms. DEGETTE. And I agree with you. And my daughter is a type 

1 diabetic, and working with her pediatric endocrinologist she 

would tell me with the type 2 issues in particular they would have 

kids referred to them at the Barbara Davis Center in Denver. And 

the regular pediatricians could not diagnose between type 1 and 

type 2 and children which used to be, as you point out, quite rare 

but with increasing obesity and lifestyle issues, and the way you 

treat these two types of diabetes can really make a difference either in life expectancy or complications. 

Can you tell me how the CHGME program could actually help 

to train additional pediatric subspecialists? 

Dr. GURALNICK. Well, the funding is incredibly important to support people going into the specialty and to support institutions having fellowships for that specialty. There is such a great need nowadays for these numbers of people and we would like to get training in fellowships in various areas. As was mentioned by the Chairman the people tend to go often, tend to stay often where they 

train and so if we can train people in more areas we are more likely to serve more areas with these endocrinologists. 

Ms. DEGETTE. And I agree with that. 

Dr. Schutze, you said in your testimony only one percent of the 

hospitals in the country are eligible to receive CHGME. In Colorado, Children’s Hospital in Aurora got just over $6 million in 

these funds. But even though these hospitals, it is only one percent 

of the hospitals they are training almost half of the pediatricians 

including the pediatric psychiatrists and other mental health specialists. I am wondering if you can talk about how CHGME supports children’s behavioral health needs. 

Dr. SCHUTZE. Sure. That is a great question. As the country goes 

on and we have gotten better in preventing infectious diseases, 

chronic diseases have become the number one issue among kids 

and adults. And certainly within that behavioral and psychiatric 

and developmental issues become very important. They are probably the number one chronic disease that we see. 

So we approach this from a number of different angles. There are 

training programs in behavioral and developmental pediatrics that 

go on that CHGME supports. There is training in 

neurodevelopmental disabilities that CHGME funds support. And 

there is training in pediatric psychiatry as well so that we are hitting this from a couple different angles. 

Ms. DEGETTE. Thanks. I just have one last question for both of 

you. The good news is we are talking about reauthorizing this. But 

last year because of the difficulties that we had, we had a number 

of short-term continuing resolutions and in fact the Community 

Health Center program in CHIP expired. I am wondering if you 

can both talk very briefly about the importance of having a level 

and dependable reauthorization is for this program. 

Doctor? 

Dr. GURALNICK. Certainly from my role I am in charge of all of 

the residency programs in my institution, and so when we authorize programs to have certain numbers of residents we need to know 

that the funding will be there. And if the funding is not consistent 

it is very difficult to say to a program, well, you can have this numVerDate Nov 24 2008 09:58 Jan 17, 2019 Jkt 037690 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-135 CHRIS
29 

ber of residents every year, because if CGHME is not available 

then the institution has to provide that funding. 

Ms. DEGETTE. You have to plan that ahead, right? 

Dr. GURALNICK. You need to plan that. And the training is several years long and so you need to know that the funding will continue to be there throughout their training and for the next people 

that you accept into the program. 

Ms. DEGETTE. I am out of time, but do you agree with that, Doctor? 

Dr. SCHUTZE. I do. And I will just say, for instance, this summer 

we will have to decide how many positions we have because interviews start in the fall and so we have to know now. And so that 

inconsistent funding makes it impossible to guarantee you have positions and so you wouldn’t advertise them, you wouldn’t fill them. 

Ms. DEGETTE. Thank you. 

Dr. SCHUTZE. Thank you. 

Ms. DEGETTE. Thank you very much, Mr. Chairman. 

Mr. BURGESS. The chair thanks the gentlelady. So the 10-year 

funding for State Children’s Health Insurance Program that passed 

this Congress earlier this year, that was OK? You all were OK with 

that? 

Dr. SCHUTZE. Yes, sir. 

Mr. BURGESS. All right, just checking. 

The gentleman from Georgia is recognized for 5 minutes for 

questions, please. 

Mr. CARTER. Thank you, Mr. Chairman, and thank both of you 

for being here. I really do appreciate it. And, Mr. Chairman, I want 

to thank you and the ranking member for introducing this reauthorization. It is critical, particularly to us in the State of Georgia. 

I served in Georgia state legislature on the Health and Human 

Services Committee and I am well aware of the shortages that we 

struggle with in the State of Georgia, particularly with physicians, 

particularly with pediatricians. 

Right now in the State of Georgia we have 130 out of the 159 

counties that we have in the State, 130 of them are considered 

healthcare professional shortage areas. And, in fact, out of the 159 

counties that we have in the State of Georgia, 61 don’t even have 

a pediatrician. Sixty one counties in the State of Georgia do not 

have a single pediatrician. Now, and a lot of those counties are in 

my district and a lot of them are in south Georgia because of the 

rural area there. 

So it is really a challenge and that is why this legislation is so 

important. That is why I am a co-sponsor on it and why I appreciate it so much. The Georgia Board for Physician Workforce estimated that the population of Georgia between the years of 2000 

and 2015 increased by 24 percent, yet we only increased the number of physicians by 9.4 percent. So obviously we are losing ground 

there and one of the things that we really struggle with is the 

residencies and that is one of the things that I wanted to ask you 

about. 

What can we do—I know that states like Georgia and Texas because of the formula that is in place we are not getting the number 

of residents that we need because it hasn’t been updated in awhile. 

Do you care to comment on that, Dr. Guralnick? 

30 

Dr. GURALNICK. From our standpoint, from the academy standpoint, and from the GME standpoint, nationally we are really 

struggling with the caps that were put in place so many years ago. 

Mr. CARTER. They were put in place when, 1996? 

Dr. GURALNICK. Yes, whatever number you had at that point. 

Mr. CARTER. And they haven’t updated since then? 

Dr. GURALNICK. Correct, even though there are many more medical students and populations have increased so drastically. And 

the level of care fortunately since there is so much more in children’s survivorship, we have many, many children with a great 

many needs, especially special healthcare needs that we are not 

having enough physicians, enough pediatricians to care for them. 

Mr. CARTER. Right. I assume it is a responsibility and I am assuming, here, this is a responsibility of the agency to update that 

formula. Or is it a responsibility of Congress, do either of you 

know? I don’t either, Mr. Chairman. I would ask—— 

Dr. SCHUTZE. I am not aware. 

Mr. BURGESS. It actually was changed during the passage of the 

Affordable Care Act but I can’t tell you the precise numbers. It is 

something we have under active surveillance on the subcommittee 

level. 

Mr. CARTER. OK. Well, I apologize. I am just not educated in who 

had responsibility of that. 

What do you think would be the best way for us to bring the slot 

allocation up to date without harming other states? Is there a way 

we could do that without really causing any pain to other states? 

Yes, increase funding, right, all across the board. 

Dr. GURALNICK. Increase funding, yes. 

Mr. CARTER. Yes, I stepped right in the middle of that, I know. 

[Laughter.] 

Dr. GURALNICK. Because you can’t damage other people. 

Mr. CARTER. Never mind. Strike that last question. 

I want to talk specifically about in Georgia again, that is what 

I represent. And the Children’s Healthcare of Atlanta, it is the 

largest pediatric residency training center that we have and because of the CHGME funding they are able to train more than 600 

residents and fellows each year and the majority come from state 

schools. So the majority of them stay. I mean we knew that. We 

found that out during the time I was serving on the legislature. If 

you can get them to do their residency in the state usually they 

will stay. That is why it so important. And we actually funded in 

the State of Georgia a number of residency, a number of slots for 

that specific purpose to increase the number of physicians. 

But I just wanted to ask you, are there certain challenges to a 

children’s hospital in particular whenever you have this in place? 

Are there certain challenges that maybe you don’t find in other 

areas, if it is just specifically for a children’s hospital? 

Dr. SCHUTZE. If I understand your correction correctly, in order 

to get people to do training with kids they have to want to deal 

with kids and not everybody wants to. So you are starting with this 

specific personality I think that want to do that. Getting them to 

come, I agree with you a hundred percent. If you want to get more 

pediatricians for Georgia, the best way to do it is to get people in 

pediatrics from Georgia and they are likely to stay there. 

31 

But it is also a maldistribution of people within Georgia, because 

they are going to stay in Atlanta and not go to the other parts. 

Mr. CARTER. Absolutely. That is why the 61 are mainly in south 

Georgia. 

Dr. SCHUTZE. Right, and so that becomes difficult then as well. 

I recruit pediatricians for our clinics in Africa and I used to work 

in Arkansas. It is a lot easier to get people to go to Africa to work 

than it is to go to the Mississippi River Delta. And somehow it is 

an adventure when you go to Africa and not so much when you go 

to the Mississippi River Delta, but people there are just as poor as 

the people we treat in Africa, et cetera. 

So this maldistribution is something that we need to address as 

educators and healthcare providers as well. And maybe it requires 

incentives to get people to go to those places as well, loan repayment, other kind of thing. 

Mr. CARTER. I know I am way over my time. Just what are your 

suggestions? How can we improve this situation? 

Dr. GURALNICK. As you said, the loan repayment is a huge incentive especially with the incredible debt that everybody has nowadays. That is probably the most straightforward way to do it. 

Dr. SCHUTZE. Right. 

Mr. BURGESS. Very well. 

Mr. CARTER. Good. And I yield back. Thank you, Mr. Chairman. 

Mr. BURGESS. The gentleman’s time has expired. The Chair 

would recognize the gentleman from Texas for a follow-up question. 

Mr. GREEN. Thank you, Mr. Chairman. 

By supporting the children’s health GME we are supporting the 

training of quality pediatric providers that help children not only 

in the United States but in some cases globally. Dr. Schutze, I understand you are quite involved in the work that Texas Children’s 

Hospital does globally. Could you discuss how the Texas Children’s 

Hospital shares its expertise with our global partners to help children around the world have greater access to specialized care? 

Dr. SCHUTZE. Sure. So we have a global health residency where 

we, actually a pediatric residency of 3 years. We have five slots 

that we take every year for a 4-year program where we send residents to work in one of our clinics in Africa and Botswana, Malawi, 

Lesotho, Swaziland, or Uganda for a year to learn about taking 

care of kids living in resource-limited areas, et cetera. About half 

of those kids come back and then do further training and some continue to do international work. 

But then some stay in our country to work with people living in 

resource-limited areas like at the FQHCs, like in the inner cities, 

et cetera, et cetera. So I think that year of working globally also 

really helps them come back to work with populations in resourcelimited areas in our own country and our own state and our own 

city. 

Mr. GREEN. Thank you. And I appreciate, because that is a partnership in Africa with Baylor and—— 

Dr. SCHUTZE. Correct. 

Mr. GREEN [continuing]. Texas Children’s, so thank you. And I 

don’t mind them coming home to service in my FQHCs. 

Mr. Chairman, I yield back. 

32 

Mr. BURGESS. The gentleman yields back. Seeing that there are 

no further members wishing to ask questions, I again want to 

thank our witnesses for taking time to be here today. I do have the 

following documents to submit for the record: a letter from the 

American Academy of Pediatrics; a letter from the Children’s Hospital Association; and a letter from Healthcare Leadership Council. 

[The information appears at the conclusion of the hearing.] 

Mr. BURGESS. Pursuant to committee rules, I remind members 

that they have 10 business days to submit additional questions for 

the record and I ask the witnesses to submit those responses within 10 business days on the receipt of those questions. So, without 

objection, the subcommittee then is adjourned. 

[Whereupon, at 2:56 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

PREPARED STATEMENT OF HON. GREG WALDEN

Good afternoon. Before us today is legislation to reauthorize the Children’s Hospital Graduate Medical Education Program. I would be remiss not to note that this 

bipartisan bill is authored by two Texans who just so happen to be the leaders of 

this subcommittee—Ranking Member Gene Green and Chairman Michael Burgess. 

H.R. 5385, the Children’s Hospital GME Support Reauthorization Act of 2018 will 

reauthorize federal funding for graduate medical education at our nation’s freestanding children’s hospitals. As you all know, Medicare remains the single largest 

payer of graduate medical education. 

First established in 1999, the Children’s Hospital Graduate Medical Education 

payment program, commonly referred to as CHGME, specifically supports children’s 

teaching hospitals, which do not receive a significant amount of federal dollars for 

their residential training programs due to the low volume of Medicare patients. By 

reimbursing these teaching hospitals for the training of physicians, CHGME builds 

pediatric health workforce, helping to ensure that every child has access to quality 

care. 

The United States is facing a severe shortage of physicians and the case is no different for pediatric specialists. Now more than ever, we must continue to support 

this vital training program for pediatricians and pediatric subspecialists in children’s hospitals. 

The authorization for this important program expires on September 30, 2018, so 

it is important we complete our work on time. 

I look forward to hearing from today’s witnesses and gaining their feedback on 

our efforts. We appreciate you all taking the time to be with us today. And lastly, 

thank you again to the Health Subcommittee Chairman and Ranking Member for 

their leadership on this issue. 

33 


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American Academy of Pediatrics DEDICATED TO THE HEALTH OF ALL CHILDREN• 

April 23,2018 

The Honorable Greg Walden 

Chairman 

U.S. House Committee on Energy 

and Commerce 

Washington, DC 20515 

The Honorable Michael Burgess 

Chairman 

Health Subcommittee 

U.S. House Committee on Energy 

and Commerce 

Washington, DC 20515 

The Honorable Frank Pallone 

Ranking Member 

U.S. House Committee on Energy 

and Commerce 

Washington, DC 20515 

The Honorable Gene Green 

Ranking Member 

Health Subcommittee 

U.S. House Committee on Energy 

and Commerce 

Washington, DC 20515 

Dear Chairman Walden, Ranking Member Pallone, Chairman Burgess, and Ranking 

Member Green: 

On behalf of the American Academy of Pediatrics (AAP), a non-profit professional 

organization of 66,000 primary care pediatricians, pediatric medical sub-specialists, and 

pediatric surgical specialists dedicated to the health, safety, and well-being of infants, 

children, adolescents, and young adults, 1 write to endorse the Children's Hospital GME 

Support Reauthorization Act of2018 (H.R. 5385). This bipartisan legislation would 

reauthorize the Children's Hospital Graduate Medical Education (CHGME) program for 

five years, providing a critical investment in America's future pediatric workforce. 

lmpmtantly, it increases the authorization level from $300 million to $330 million, 

recognizing the need to continue to build on the past success of this program with 

additional funding and in line with increased funding provided through the 

appropriations process. 

Funding from the CHGME program is necessary to maintain the number of pediatric 

residents and fellows in the United Stales and represents a major step toward 

accomplishing the goal of providing freestanding children's hospitals with similar levels 

of GME funding that other hospitals current receive through the Medicare program. 

Despite representing less than one percent of hospitals, freestanding children's hospitals 

train half of all pediatricians and pediatric subspecialists. CHGME provides these 

hospitals with the means to maintain and expand teaching programs to pediatric 

residents and fellows. 

Through the CHGME program. participating children's hospitals have improved their 

training experience for residents and fellows and have created new and innovative 

programs to provide more comprehensive care to underserved communities in urban and 

rural areas. CHGME provides essential support not only to pediatric primary care, but 

also to pediatric subspecialty care, an area for which there arc serious demonstrated 

workforce shortages across the country. 
34 


33535.011

American Academy of Pediatrics 

Page2 

Thank you for your strong commitment to the health and well-being of children, and we look 

forward to working with you to move this important legislation forward. 

Sincerely, 

~a J0ap:; 

Colleen A. Kraft, MD, F AAP 

President 

CK/jdb 
35 


33535.012

April2, 2018 

CHILDREN'S 

HOSPITAL 

ASSOCIATION 

The Honorable Michael Burgess, M.D. 

Chairman 

Subcommittee on Health 

Committee on Energy and Commerce 

United States House of Representatives 

Washington, DC 20515 

Dear Chairman Burgess and Ranking Member Green, 

600 13TH ST., NW, SUITE 500 

WASHINGTON, DC 20005 

p 1 202-753-55oo 

r 1 202-347-5147 

16011 COLLEGE BLVD., SUITE 250 

LENEXA, KS 66219 

pi 913-262-1436 

f I 913-262-1575 

WWW.CHILD R ENSHOSPITALS.ORG 

The Honorable Gene Green 

Ranking Member 

Subcommittee on Health 

Committee on Energy and Commerce 

Cnited States House of Representatives 

Washington, DC 20515 

On behalf of America's children's hospitals and the patients and families we ser,re, thank you for introducing, 

H.R. 5385, "The Children's Hospital GME Support Act of 2018." \Xlc applaud your unwavering 

determination to advocate for children's health. 

The bipartisan leadership you have shown not only in this congress but over the past several years in 

championing CHGME has been instrumental to building and maintaining support in congress for this 

important program. The future of pediatric health care cannot be compromised. CHGME has a proven 

track record of success and represents a high-value investment in children's health care. \Xle deeply appreciate 

the opportunity to work ·with you to ensure children's hospitals in Texas and throughout the country maintain 

the ability to train the best and brightest doctors to treat our nation's children. 

The CJ IGME program supports child health nationally by funding the training of pediatric providers at 

eligible children's hospitals. CHGI\1E recipient hospitals- only 1 percent of all hospitals- train 

approximately half of the nation's pediatricians and pediatric specialists, more than 7,000 annually. \\bile 

CHGME has been successful in promoting access to care, much remains to be done. Serious workforce 

shorlages persist, most acutely among pediatric specialties, though localized shortages of pediatric primary 

care also continue in certain areas. Reauthorizing the program for an additional five years and increasing the 

authorization level to $330 million, as called for under I LR. 5385, will allow children's hospitals to maintain 

and grow training programs that target the unique needs of children. 

\Ve also wish to acknowledge the excellent work of your staff, in particular Edward Kim and Sergio Espinosa, 

in support of advancing reauthorization. Their contributions arc invaluable to the success of this bipartisan 

effort. 

\X-7e look fot'W'ard to working with you to achieve passage of I·I.R. 5385 this year. Thank you again for your 

leadership and support of children's health. 

V cry best regards, 

Mark \~ ictecha 

President and Chief Executive Officer 

Children's Hospital1\ssociation 

Champions for Children's Health 
36 


33535.013

May 23, 2018 

HEAI:fHCARE 

LEADEiZSHIP 

The Honorable Michael C. Burgess, M.D. 

Chairman 

Subcommittee on Health 

Committee on Energy and Commerce 

United States House of Representatives 

Washington, D.C. 20515 

Dear Chairman Burgess: 

As the Subcommittee holds a hearing on the Children's Hospital Graduate Medical 

Education (CHGME) program, the Healthcare Leadership Council (HLC) welcomes the 

opportunity to share its thoughts with you. 

HLC is a coalition of chief executives from all disciplines within American healthcare. It 

is the exclusive forum for the nation's healthcare leaders to jointly develop policies, 

plans, and programs to achieve their vision of a 21st century healthcare system that 

makes affordable, high-quality care accessible to all Americans. Members of HLChospitals, academic health centers, health plans, pharmaceutical companies, medical 

device manufacturers, laboratories, biotech firms, health product distributors, 

pharmacies, post-acute care providers, and information technology companies -

advocate for measures to increase the quality and efficiency of healthcare through a 

patient-centered approach. 

Keeping children healthy by giving them access to care is essential to the wellbeing of 

our society. Diagnosing and treating problems at an early age increases the likelihood 

that children will grow into healthy adults. This care will also save costs, as these 

children will be more likely to be able to work and contribute to our nation's economy in 

the future. 

To care for these vulnerable patients, the United States requires a strong and stable 

pediatric healthcare workforce. CHGME funds the training of pediatric providers at 

eligible children's hospitals that, because they treat only a small number of Medicare 

beneficiaries, rely on CHGME to fund their residency positions. These hospitals train 

half of the nation's pediatricians, and more than 65 percent of pediatric specialists. 

However, there are still shortages in this workforce that make it difficult for children to 

access care. These shortages are made worse by current CHGME funding that 

represents only half of what Medicare GME provides to general acute care hospitals on 

a per-resident basis. 
37 


33535.014

H.R. 5385, the "Children's Hospital GME Support Reauthorization Act," would help to 

address this funding shortfall by reauthorizing the program for five years at $330 million 

per year. HLC thanks you for introducing this important bill and urges the 

Subcommittee to support it. 

Thank you again for your commitment to CHGME. HLC looks forward to continuing to 

work with you on our shared priorities. Should you have any questions, please do not 

hesitate to contact Debbie Witchey at (202) 449-3435 or dwitchey@hlc.org. 

Mary R. Grealy 

President 

2 
38 

Æ 


33535.015

American 

~ Hospital 

Association. 

April4, 2018 

The Honorable Michael C. Burgess, MD 

Chairman 

Subcommittee on Health 

House Committee on Energy and Commerce 

United Stales House of Representatives 

Washington, DC 20515 

Dear Chairman Burgess: 

80010thStreet.W</ 

Two CityCenter, Sufte 400 

Washington, oc mn-4956 

{202)6:J8.1100Phone 

\WJW.aha.org 

On behalf of our nearly 5,000 member hospitals, health systems and other health care 

organizations, and our clinical partners- including more than 270,000 affiliated physicians, 2 

million nurses and other caregivers- and the 43,000 health care leaders who belong to our 

professional membership groups, the American Hospital Association (AHA) wishes to express 

support for the Children's Hospital GME Support Reauthorization Act of2018 (H.R. 5385), 

which would reauthorize the Children's Hospitals Graduate Medical Education (CHGME) 

program for an additional five years and fund the program annually at $330 million. 

Congress created the CHGME program in 1999 to support graduate medical education programs 

at children's hospitals that train resident physicians, as well as enhance research capabilities and 

care for poor and medically underservcd children in rural and inner-city areas. The program 

provides funding to 58 independent children's hospitals in more than 30 states to train primary 

care pediatricians. Children's hospitals treat very few Medicare patients; therefore, they do not 

receive Medicare funding to support medical training of residents. The CHGME program helps 

to offset this inequity. CHGME helps independent children's hospitals train over 45 percent of 

general pediatricians, 57 percent of pediatric specialists and the majority of pediatric researchers. 

We appreciate your leadership on this issue and look forward to working with you to advance 

this legislation. 

(:1dJJU. 

Thomas 

1

P. J~cls Executive Vice President