[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
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
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
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COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
CHRIS COLLINS, New York SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
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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
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.
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 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 million 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, pediatric subspecialists,
neonatologists, pediatric psychiatrists, adolescent health
specialists as well as other physician types in non-pediatric
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 non-pediatrics-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.
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 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 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.
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
expenses 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:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
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 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:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
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 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.
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.
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.
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 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 Dallas-Fort 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.
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 number 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?
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.
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 resource-limited 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.
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.
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