The Obama administration’s bid to slash funding for training pediatricians at children’s hospitals is provoking intense protests from medical educators and lawmakers on both sides of the aisle.
Earlier this year, the administration, as part of its 2012 budget, proposed terminating a program that provides more than $300 million a year to the 56 free-standing children’s hospitals around the country, which train 40 percent of the nation’s pediatricians and 43 percent of pediatric sub-specialists. In addition, it cut $48 million from the program last month as part of the overall spending reductions for the current year that were in the budget agreement reached with Congress.
But children’s hospitals officials say ending the 12-year program, called the Children’s Hospital Graduate Medical Education payment program, or CHGME, could cause a raft of problems.
“I can certainly envision a scenario where we just can’t train enough folks,” said Josh Greenberg, vice president for government relations for Children’s Hospital Boston. “I think there’s a real danger that a confluence of factors is going to make access to care for kids incredibly difficult.”
Members of Congress, including Sens. Robert Casey Jr., D-Pa., and Johnny Isakson, R-Ga., and Reps. Joe Pitts, R-Pa., and Frank Pallone Jr., D-N.J., have introduced bills to save the program.
Pitts' communications director, Andrew Wimer, said he believes the administration chopped the program because “the health law left only crumbs for pediatric training and subspecialty training.” The Pitts- Pallone bill and the companion bill in the Senate call for reauthorizing CHGME for five years.
The program was enacted in 1999 to provide children’s hospitals with funding for residencies and fellowships, the training that physicians get in a hospital once they leave medical school. Although Medicare and other federal programs also provide funding for residencies, the bulk of the money goes to hospitals generally serving adults.
Since the program was put into place, the number of pediatric residents has increased 35 percent, said James Kaufman, vice president for public policy for the National Association of Children’s Hospitals. That was a reversal of the 13 percent decline in the 1990s. Much of the increase, he said, is attributable to a rise in the training of pediatric sub-specialists.
“We didn’t have a child neurology fellowship before CHGME,” said Morna Smith, director of federal relations and health policy at Nationwide Children’s Hospital in Columbus, Ohio. “Try to imagine waiting two months to find out why your kid is having seizures.” Today, “we have six pediatric neurology fellows.” The hospital has also more than tripled the number of pediatric neurologists on staff, from six to 19, because a number of the fellows stay once they complete their training. The upshot, says Smith, is that “we’ve doubled the number of outpatients we can see in a year.”
Martin Kramer, the director of communications for the Health Resources and Services Administration, the agency within the Department of Health and Human Services that oversees the disbursement of funds for physician training, blamed the 2012 proposed cuts on a “challenging budget environment” that “required proposing spending reductions that we may not have had to make in different circumstances.”
Kramer pointed out that the agency has a number of other programs for training primary care doctors that will benefit pediatrics, including the Teaching Health Center Graduate Medical Education Program and the Primary Care Residency Expansion Program; those programs have money guaranteed by the health law. But children’s hospital advocates say those and similar federal programs are available to all teaching hospitals, including those that treat adults, so there is no guarantee children's hospitals will be able to get enough funding to continue their training programs.
The White House Office Management and Budget, in a report on proposed budget cuts, said ending CHGME will redirect "resources to … activities that will support the training of more primary care physicians." It argues that the change is needed because “current estimates project the United States will face a shortage of primary care physicians.”
Administrators at children's hospitals are not the only ones surprised by the administration's effort to cut CHGME. “It’s an odd thing to say that you want to shift this money over to the primary care workforce,” said Dr. Atul Grover, chief advocacy officer for the Association of American Medical Colleges, a not-for-profit association representing medical schools, teaching hospitals and health systems. “We’re doing a great job of keeping kids alive longer if they have problems from birth or pediatric cancers. But you still have to figure out how you’re going to take care of them after acute events.” Specialists are needed to help those children, he said.
Dr. Sheldon Retchin, vice president for health sciences at Virginia Commonwealth University in Richmond and a past member of the Council of Graduate Medical Education, concurred. “I certainly share the president’s concern and Washington’s concern in general that we need to right-size the workforce.” But, he said, “I think diverting money is probably a little premature. I’m unaware of any study that says we’re oversupplied with pediatricians.”
Even with CHGME, gaps remain. “The waiting list for some specialties is more than three months,” said Dr. Susan Wu, director of the community pediatrics and advocacy program at Children’s Hospital Los Angeles. “And this is LA, with a few different pediatric tertiary centers. I’m not even thinking about folks who live in Nevada or Montana, where they don’t have a lot of pediatric training programs.”