[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
                        
                        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
33-535                      WASHINGTON : 2019                     
          
-----------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].                         
                    
                
                    
                    
                    
                    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

                              ----------                              
                                                                   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.
                              ----------                              


[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


                                 [all]