Children’s Hospitals Graduate Medical Education (CHGME)

Children’s Hospitals Graduate Medical
June 13, 2023
Education (CHGME)
Elayne J. Heisler
The Children’s Hospitals Graduate Medical Education (CHGME) program provides direct
Acting Section Research
financial support to children’s hospitals to train medical residents and fellows. The program is
Manager
administered by the Health Resources and Services Administration (HRSA) within the

Department of Health and Human Services (HHS) and is authorized in Section 340E of the
Public Health Service Act (PHSA). CHGME receives annual discretionary appropriations, and its

funding has increased in recent years. The program was funded at $375 million in FY2022 and
$385 million in FY2023.
Hospitals typically receive support for graduate medical education (GME) through Medicare, and those payments are
provided to hospitals based on their Medicare patient volume. Because the Medicare program is used primarily by people
who are over the age of 65, and children’s hospitals treat primarily people below the age of 18, children’s hospitals have low
Medicare patient volume and receive few Medicare GME payments.
Prior to the CHGME program, advocates argued that the lack of direct federal support for GME in children’s hospitals
impeded the development of the pediatric workforce. Program proponents argued that children’s hospitals, rather than general
hospitals, are more likely to have the patient volume necessary to train pediatric subspecialists. Since the program was
created in 1999, the size of the pediatric subspecialty workforce has increased. The CHGME program supports the training of
nearly half of general pediatricians and more than half of all pediatric subspecialists. In the most recent year for which final
training data are available (academic year 2021-2022), the program provided financial support to more than 8,224 medical
residents and fellows. In FY2021, the program supported training at 59 free-standing children’s hospitals located in 29 states,
the District of Columbia, and Puerto Rico.
The program’s appropriations were reauthorized in 2018 by P.L. 115-241, the Dr. Benjy Frances Brooks Children’s Hospital
GME Support Reauthorization Act of 2018, which extended the program’s authorizations of appropriations until FY2023 and
increased the amount authorized to $325 million. The reauthorization did not include substantive changes to the program. In
FY2022 and FY2023, the amount appropriated exceeded the authorized amount. The CHGME program also provides
additional quality bonus funding to children’s hospitals that meet certain training criteria. Measuring, reporting, and
rewarding quality training is unique to this program as compared with other sources of federal GME support.
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Contents
CHGME Purpose and Program Structure ........................................................................................ 1
Program Origins .............................................................................................................................. 2
CHGME Authorization and Appropriations .................................................................................... 4
CHGME Payments .......................................................................................................................... 6
CHGME Quality Bonus System ............................................................................................... 8
CHGME Eligible Hospitals and Payment Distribution ................................................................... 9
CHGME Residents Trained ........................................................................................................... 10
Other Sources of GME Funding for Children’s Hospitals ............................................................ 12
Concluding Observations .............................................................................................................. 14

Tables
Table 1. Children’s Hospitals GME Funding and Authorizing Legislation ..................................... 5
Table 2. Children’s Hospital GME Funding in FY2022, by State ................................................. 10
Table 3. Number of Residents Trained and Hospitals Receiving CHGME Awards
FY2000-FY2024 (proposed) ....................................................................................................... 11

Table A-1. Children’s Hospitals that Received CHGME Support, FY2000-FY2022 ................... 15

Appendixes
Appendix. Children’s Hospitals that Received CHGME .............................................................. 15

Contacts
Author Information ........................................................................................................................ 18


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Children’s Hospitals Graduate Medical Education (CHGME)

he Children’s Hospitals Graduate Medical Education (CHGME) program provides direct
financial support to children’s hospitals—those that treat primarily patients below the age
T of 18—to train medical residents and fellows. The program is administered by the Health
Resources and Services Administration (HRSA) within the Department of Health and Human
Services (HHS) and is authorized in Section 340E1 of the Public Health Service Act (PHSA).2
CHGME receives annual discretionary appropriations, which are authorized through FY2023.
The use of discretionary appropriations to fund CHGME differs from other federal sources of
graduate medical education (GME) support. For example, Medicare—the largest source of GME
payments—is mandatory.3 More information on other GME programs and how programs interact
is available in CRS Report R44376, Federal Support for Graduate Medical Education: An
Overview
.
This report describes the CHGME program’s (1) purpose and structure, (2) history, and (3)
authorizations and appropriations. It also provides select program data, including the number of
hospitals supported under the program, their location, the amount of funding they receive, and the
number of residents trained. Finally, the report discusses alternative sources of GME funding
available.
CHGME Purpose and Program Structure
As detailed in the text box below, the CHGME program provides direct financial support to
children’s hospitals to train medical residents and fellows.
Medical Residents and Fellows
“Medical resident” refers to medical school graduates who directly enter into training in a specialty who, after
the completion of such training, are eligible to become board certified in that specialty. In the case of CHGME, the
majority of support provided is for pediatric residents.
“Fellow” refers to medical school graduates who have completed their residency training and are pursuing
additional training, called a fellowship, after which they are eligible to become board certified in a subspecialty. In
the case of CHGME, such fellows would be individuals training in pediatric medical subspecialties (such as pediatric
cardiology or pediatric gastroenterology) or pediatric surgical subspecialties (such as pediatric trauma surgery or
pediatric cardiothoracic surgery). Pediatric subspecialists are qualified to provide patient care or conduct research
in an organ-specific area of medical or surgical care for children.
Both residents and fellows must be training in a program accredited by either the Accreditation Commission for
Graduate Medical Education or the American Osteopathic Association. The two accreditors transitioned to a joint
accreditation system in 2020; therefore, effectively, the Accreditation Council for Graduate Medical Education is
the active accreditor.
Source: CRS analysis of 42 U.S.C. §256e and CRS Report R44376, Federal Support for Graduate Medical Education:
An Overview
. For information on program accreditation and the transition to a single accreditation system, see
Accreditation Council for Graduate Medical Education, “The Single GME Accreditation System,”
https://www.acgme.org/What-We-Do/Accreditation/Single-GME-Accreditation-System/.
The CHGME program provides GME funds to “free-standing children’s hospitals,” which are
hospitals that have a patient population that is primarily under the age of 18. Free-standing
children’s hospitals specialize in treating children, but are not part of a larger hospital system. For
example, a general teaching hospital may offer pediatric training as part of its integrated services,
or perhaps as part of a dedicated children’s center, but such a center would receive Medicare

1 42 U.S.C. §256e.
2 42 U.S.C. §§201 et seq.
3 The Medicare program provided an estimated $16.2 billion in GME payments in FY2020. CRS In Focus IF10960,
Medicare Graduate Medical Education Payments: An Overview.
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GME support as part of the larger hospital’s GME programs. Such a center would not be
considered to be a free-standing children’s hospital, and, therefore, would not be eligible for
CHGME.
Hospitals eligible to participate in CHGME must have a Medicare Provider Agreement, and must
be excluded from the Medicare Inpatient Prospective Payment System (IPPS).4 In addition,
CHGME-eligible hospitals must operate programs that train pediatricians, or pediatric medical or
surgical subspecialists, and these programs must be accredited (see text box above for
definitions).5 The 2013 program reauthorization, discussed below, expanded the program to make
additional hospitals eligible for a subset of the program’s appropriation.6 These hospitals were
defined as (1) free-standing; (2) having a Medicare payment agreement and being excluded from
the Medicare IPPS; (3) having an inpatient population composed predominantly of individuals
under 18 years of age; and (4) having an approved medical residency training program, but not
one qualified to receive Medicare GME payments.7 The Government Accountability Office
(GAO) examined the newly eligible programs and found that the new programs included one
psychiatric hospital and three hospitals that had not previously participated in the program.8
Program Origins
The CHGME program was created in the Healthcare Research and Quality Act of 1999 (P.L. 106-
129), which authorized payments to children’s hospitals for FY2000 and FY2001 to support
medical residency training. Medicare—which provides approximately $16.2 billion to support
residency training9—is the largest supporter of medical residency training, but the level of
Medicare support at any hospital is based on the volume of services that the hospital provides to
Medicare beneficiaries. Because the Medicare program is used primarily by people who are over
the age of 65, and children’s hospitals treat primarily people below the age of 18, children’s
hospitals have low Medicare patient volume and receive few Medicare GME payments.
Prior to the program’s inception, advocates argued that the lack of direct federal support for GME
in children’s hospitals impeded the development of the pediatric workforce because children’s
hospitals, rather than general hospitals, are more likely to have the patient volume necessary to
train pediatric subspecialists.10 To operate an accredited training program, a hospital must have

4 Social Security Act 1886(d)(1)(B)(iii).
5 U.S. Department of Health and Human Services, Health Resources and Services Administration, “Children’s Hospital
Graduate Medical Education Payment Program,” http://bhpr.hrsa.gov/childrenshospitalgme/index.html.
6 Specifically, it permitted the newly eligible hospitals to receive GME payments from up to $7 million from an amount
that was up to 25% of the total amount of the CHGME appropriation that exceeds $245 million.
7 42 U.S.C. §254e(h).
8 U.S. Government Accountability Office, Physician Workforce: Expansion of the Children’s Hospital Graduate
Medical Education Payment Program
, 18-66R, October 31, 2017.
9 CRS In Focus IF10960, Medicare Graduate Medical Education Payments: An Overview.
10 The American Academy of Pediatrics, the major professional association for pediatricians, released a 2000 report
detailing shortages in pediatric subspecialties and calling for additional financial support for training and research. See
Alan Gruskin et al., “Final Report of the FOPE II Pediatric Subspecialists of the Future Workgroup,” Pediatrics, vol.
106, no. 5 (November 2000), pp. 1224-1244. The Academy released another workforce statement in 2013, which also
called for more training. See Committee on Pediatric Workforce, American Academy of Pediatrics, “Pediatrician
Workforce Policy Statement,” Pediatrics, vol. 132 (July 29, 2013), pp. 390-397. More recent research found that the
number of pediatric subspecialists have grown, but that some areas still lack access to pediatric subspecialty care. See
Adam Turner, Thomas Ricketts, and Laurel K. Leslie, “Comparison of Number and Geographic Distribution of
Pediatric Subspecialists and Patient Proximity to Specialized Care in the US Between 2003 and 2019,” JAMA
Pediatrics
, vol. 174, no. 9 (May 18, 2020), pp. 852-860.
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sufficient patient volume to ensure that residents receive the full measure of training in a given
field. As such, children’s hospitals are more likely to have the range of cases necessary to train
pediatric subspecialists who focus on specific pediatric conditions or types of surgery in
children.11
Since the CHGME program began, the size of the pediatric subspecialty workforce has
increased.12 Despite these increases, some children lack access to pediatric subspecialty care (see
text box), with long wait times for children to access certain types of pediatric subspecialists.13
Moreover, some children’s hospitals report physician vacancies and difficulties hiring in certain
subspecialties.14 Researchers have found that some geographic areas have a shortage of pediatric
subspecialists, leading some children to seek care with subspecialists who focus on adults, which
may adversely affect the care the children receive.15 In contrast, future projections find growth in
the pediatric generalist population that exceeds growth in demand for pediatricians.16 In addition,
other projections find that because of fertility declines, future demand for pediatric subspecialists
will be less than current demand.17 However, projections are limited by the assumptions made,
which generally assume that the future workforce will follow the same employment patterns as
the current workforce. Researchers have found increasing numbers of pediatricians working part
time, which may affect whether future surpluses are realized.18
Access to, and the Geographic Distribution of, the Pediatric
Subspecialty Workforce
Although the size of the pediatric subspecialty workforce has increased since the CHGME program began, some
geographic areas do not have access to these providers. Researchers have found that the overall increase between
2002 and 2016 was relatively smal (an additional two providers per 100,000). Children’s hospitals provide on
average 30% of all pediatric inpatient care and have more pediatric subspecialty care types than do other types of
hospitals. Children’s hospital providers are generally also teaching and conducting research and not providing ful -
time clinical care. Overall, pediatric subspecialists report working fewer hours in direct patient care, which may
mean that the increase of subspecialists may not translate ful y into increased access to care. In addition, children’s
hospitals are generally located in urban areas, which may make the care they provide less accessible to rural
populations. Researchers have found that there are shortages and a maldistribution of the pediatric workforce,
which affects access to care in rural areas, where family medicine physicians are more common than pediatricians.
Despite access to care from family medicine physicians (who treat patients across the lifespan), the majority of
children in the United States are treated by pediatricians and pediatric subspecialists. Researchers have found that
low ratios of certain subspecialties per population and that this translates into longer wait times to access care. In
addition, growing numbers of children have complex health care needs and chronic conditions, with approximately

11 Both general hospitals and children’s hospitals may have sufficient patient volume to train general pediatricians.
12 See House Consideration and Passage of S. 1557, Congressional Record, daily edition, vol. 160 (April 1, 2014), pp.
H2782-H2784.
13 Children’s Hospital Association, Pediatric Workforce Shortages Persist, Pediatric Workforce Shortage Fact Sheet,
Washington, DC, January 19, 2018, https://www.childrenshospitals.org/Issues-and-Advocacy/Graduate-Medical-
Education/Fact-Sheets/2018/Pediatric-Workforce-Shortages-Persist.
14 Ibid.
15 Kristin N. Ray et al., “Use of Adult-Trained Medical Subspecialists by Children Seeking Medical Subspecialty
Care,” Journal of Pediatrics, vol. 176 (September 2016), pp. 173-181.
16 Health Resources and Services Administration, Health Workforce, National Center for Health Workforce Analysis,
Health Workforce Projections: General Pediatricians, Rockville, MD, April 2017, https://bhw.hrsa.gov/sites/default/
files/bureau-health-workforce/data-research/pediatrician-fs-51817.pdf.
17 IHS Markit Ltd., The Complexities of Physician Supply and Demand: Projections from 2019 to 2034, Association of
American Medical Colleges, Washington, DC, June 2021.
18 Robert J. Vinci, “The Pediatric Workforce: Recent Data Trends, Questions and Challenges for the Future,”
prepublication 2021, pp. https://pediatrics.aappublications.org/content/pediatrics/early/2021/03/08/peds.2020-
013292.full.pdf.
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20% of children identified as having special health care needs. Researchers have also found that areas with higher
percentages of the population below the federal poverty level have less access to subspecialty care and that there
are fewer pediatric subspecialists in the Mountain States (Arizona, Colorado, New Mexico, and Utah) and West
North Central States (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota). Less is
known about the implications of lack of access on children’s health. One study examined this issue in Pennsylvania
and found that children who lived in counties without pediatric subspecialists have higher rates of emergency
room visits, but it did not otherwise find differences in diseases burden (e.g., differences in days of schools
missed). The authors speculate that general pediatricians in areas without pediatric subspecialists may compensate
for this shortage by managing patients’ conditions in cases where they would otherwise refer to a subspecialist.
The authors speculate that it might be possible to ameliorate geographic and overall shortages by training general
pediatricians to manage patients’ specialty conditions more effectively.
Sources: Gary L. Free, “The Pediatric Subspecialty Workforce Is More Complex Than Meets the Eye,” JAMA
Pediatrics
, (June 28, 2021); David M. Keller, Mathew M. Davis, and Gary L. Free, “Access to Pediatric Subspecialty
Care for Children and Youth: Possible Shortages and Potential Solutions,” Pediatric Research, vol. 87 (April 15,
2020), pp. 1151-1152; Michelle L. Mayer, “Disparities in Geographic Access to Pediatric Subspecialty Care,”
Maternal and Child Health Journal, vol. 12, no. 5 (September 2008), pp. 624-63; Kristin N. Ray et al., “Supply and
Utilization of Pediatric Subspecialist in the United States,” Pediatrics, vol. 133, no. 6 (2014), pp. 1061-1069 and
Shetal Shah and Tina L. Cheng, “Optimizing the Children’s Hospital Graduate Medical Education Payment Program
at a Time of Pediatric Workforce Challenges and Health Need,” Pediatrics, vol. 245 (2022), pp. p4-6.E2.
Note: The American Academy of Pediatrics and the American Board of Pediatrics—the professional association
for pediatricians and the certifying board for pediatricians, respectively—have developed pediatric subspecialty fact
sheets at the state level that also calculates driving distance to specialty care by state; for these estimates, see
https://www.aap.org/en/advocacy/pediatric-subspecialty-shortages-fact-sheets/.
HRSA’s program data indicate that CHGME plays a significant role in training nearly half of the
pediatric physician workforce. HRSA data show that the program provided financial support to
more than 13,000 medical residents and fellows in the 2019-2020 academic year (the last year of
final data available).19 Among those supported, 41% were pediatric residents, 25% were pediatric
subspecialty residents or fellows, 3% were dental residents, and approximately 30% were
residents training in adult medical or surgical specialties who would have rotated to a children’s
hospital for part of their training.20
CHGME Authorization and Appropriations
The program was created in the Healthcare Research and Quality Act of 1999 (P.L. 106-129),
which authorized payments to children’s hospitals for FY2000 and FY2001 to support medical
resident training. The program’s appropriations were then reauthorized through FY2005 in the
Children’s Health Act of 2000 (P.L. 106-310). That law also made changes to the program’s
payment methodology and reporting requirements. The program was unauthorized, but it received
appropriations in FY2006. It was then reauthorized for a third time in the Children’s Hospital
GME Support Reauthorization Act of 2006
(P.L. 109-307), which reauthorized the program from
FY2007 through FY2011. It was subsequently reauthorized for the fourth time in 2013—in the
Children’s Hospital Reauthorization Act of 2013 (P.L. 113-98)—which authorized appropriations
from FY2014 through FY2018. The 2013 reauthorization broadened the definition of hospitals
eligible to participate to include children’s psychiatric hospitals and hospitals that had not been
able to participate in the program for technical reasons (i.e., those that HRSA had determined did

19 U.S. Department of Health and Human Services, Health Resources and Services Administration, “HRSA Health
Workforce: Children’s Hospital Graduate Medical Education Program, Academic Year 2019-2020,”
https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/funding/chgme-accomplishments.pdf.
20 Ibid.
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not technically meet the statutory definition in PHSA Section 340E).21 This reauthorization also
established a quality bonus system to provide bonus payments to CHGME-participating hospitals
that meet quality standards established by the HHS Secretary. These standards are to include, for
example, improving interpersonal and communication skills of residents, delivering patient-
centered care, and practicing in integrated health systems, such as by training in community-
based health settings. The law required the Secretary to collaborate with stakeholders in
developing these quality standards.22 Finally, the program was most recently reauthorized from
FY2019 through FY2023 in 2018 in the Dr. Benjy Frances Brooks Children’s Hospital GME
Support Reauthorization Act of 2018 (P.L. 115-241). This reauthorization increased the amount of
funding authorized and extended the period of the program’s authorization of appropriations to
FY2023. The reauthorization did not include substantive program changes.
The CHGME program has received funding since its inception, despite a lapse in authorization in
FY2006, FY2012, and FY2013. Table 1 presents funding and authorizing history from FY2000
to FY2023.
Table 1. Children’s Hospitals GME Funding and Authorizing Legislation
Appropriation
Authorizing
Year
(in millions)
Legislation
Authorized Level
2000
$40.0
P.L. 106-129
$280 mil ion
2001
$235.0
P.L. 106-129
$285 mil ion
2002
$284.9
P.L. 106-310
Such sums as may be necessary
2003
$290.1
P.L. 106-310
Such sums as may be necessary
2004a
$303.2
P.L. 106-310
Such sums as may be necessary
2005
$300.7
P.L. 106-310
Such sums as may be necessary
2006
$296.8
Authorization Expired
Not applicable
2007
$297.0
P.L. 109-307
$330 mil ion
2008
$301.6
P.L. 109-307
$330 mil ion
2009
$310.0
P.L. 109-307
$330 mil ion
2010
$316.8
P.L. 109-307
$330 mil ion
2011
$268.4
P.L. 109-307
$330 mil ion
2012
$265.2b
Authorization Expired
Not applicable
2013
$251.2
Authorization Expired
Not applicable
2014
$264.3
P.L. 113-98
$300 mil ion
2015
$265.0
P.L. 113-98
$300 mil ion
2016
$294.3
P.L. 113-98
$300 mil ion
2017
$299.3c
P.L. 113-98
$300 mil ion
2018
$315.0
P.L. 113-98
$300 mil ion
2019
$325.0b
P.L. 115-241
$325 mil ion
2020
$340.0b
P.L. 115-241
$325 mil ion
2021
$350.0b
P.L. 115-241
$325 mil ion

21 See House Consideration and Passage of S. 1557, Congressional Record, daily edition, vol. 160 (April 1, 2014),
pp. H2782-H2784.
22 P.L. 113-98. Note that these standards did not exist at the time of 2013 reauthorization and have since been
developed (see “CHGME Quality Bonus System”).
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Appropriation
Authorizing
Year
(in millions)
Legislation
Authorized Level
2022
$375.0d
P.L. 115-241
$325 mil ion
2023
$385.0d
P.L. 115-241
$325 mil ion
2024
Proposed $385.0d
Expirede
Expirede
Source: CRS Analysis of Congressional Justifications FY2000-FY2024 from the Health Resources and Services
Administration. See U.S. Department of Health and Human Services, “Budgets in Brief and Performance
Reports,” https://www.hhs.gov/about/agencies/asfr/budget/budgets-in-brief-performance-reports/index.html, and
Department of Health and Human Services, Health Resources and Services Administration, About HRSA,
“Budget,” for more recent budget years.
a. P.L. 108-490 amended how newborn infants were counted for indirect GME expenses beginning in FY2005.
b. The President’s Budget for FY2012, FY2019, FY2020, and FY2021 did not request funding for this program.
Instead, in these years it proposed consolidating CHGME with other HHS sources of GME support. This
proposal was not enacted in any of the requested years.
c. The FY2017 President’s Budget proposed making CHGME mandatory funding; however, this proposal was
not enacted.
d. Final amount included in the FY2024 President’s Budget Request. See U.S. Department of Health and
Human Services, FY024: Health Resources and Services Administration: Justification of Estimates for Appropriations
Committee
, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-fy2024.pdf, p. 48,
174.
e. Under current law, the program’s authorization of appropriation is through FY2023; therefore, unless
legislation is enacted before the start of FY2024, the program’s authorization wil be expired in FY2024.
CHGME Payments
CHGME payments are structured similarly to Medicare GME payments. In both programs,
hospitals receive two types of payments: direct and indirect. Direct payments are intended to
cover the salary and benefits of residents and their supervisors, as well as other costs associated
with operating a residency training program, including space and administrative support. Indirect
payments are made to hospitals to offset the cost a hospital incurs from training residents; for
example, for the extra tests they order as part of their training, and for the reduced productivity of
hospital staff.23 The CHGME program uses formulas to derive hospital-specific payment amounts
similar to those used in the Medicare program (see text box).
Children’s Hospitals Graduate Medical Education Payments
Direct Graduate Medical Education (DGME) Payments: The amount determined by fiscal year for direct
expenses associated with operating an approved GME program. It is a formula of the per resident amount (PRA)
multiplied by the average number of ful -time equivalent residents training in approved medical residency training
programs.

23 Medicare Payment Advisory Commission’s June 2009 Report to Congress: Improving Incentives in the Medicare
Program
, Chapter 1, at http://www.medpac.gov/docs/default-source/reports/Jun09_EntireReport.pdf and June 2010
Report to Congress:
Aligning Incentives in Medicare, Chapter 4, at http://medpac.gov/docs/default-source/reports/
Jun10_EntireReport.pdf?sfvrsn=0; and Committee on the Governance and Financing of Graduate Medical Education;
Board on Health Care Services and Institute of Medicine, Graduate Medical Education That Meets the Nation’s Health
Needs
, ed. Jill Eden, Donald Berwick, and Gail Wilensky (Washington, DC: National Academies Press, 2014). Both of
these reports also note the possibility that, in some cases, residents (particularly those in later years of training) may
generate revenue for the hospital where they are training. Other research has also found that hospitals using residents
may have lower costs per case with similar outcomes when compared to similar cases that did not have residents
participating in their care. See Jose A. Perez et al., “Comparison of Direct Patient Care Costs and Quality Outcomes of
the Teaching and Non-Teaching Hospitalist Service at a Large Academic Medical Center,” Academic Medicine, vol.
93, no. 3 (February 2018), pp. 491-497.
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PRA: The per resident amount (PRA) is hospital specific. It is a rol ing average of resident counts using three
years of cost report data, weighted by the number of ful -time primary care (i.e., pediatric) and non-primary-care
residents (i.e., pediatric subspecialty). The amount is calculated using expenses allowed under Section 1887(h)(2)
of the Social Security Act, as calculated using hospital cost reports from FY1997. The amount is further
standardized to account for wage- and nonwage-related expenses and geographic differences in wages. The PRA is
updated annually by the consumer price index for urban consumers.
Indirect Graduate Medical Education (IME) Payments:
IME payments are for the indirect expenses
associated with the treatment of more severely il patients and the additional costs of teaching residents in an
approved GME program. IME is calculated by taking into account the case mix of a children’s hospital and its ratio
of residents to beds (not including those occupied by healthy newborn infants). The IME amount is based on a
rol ing average of residents-to-beds, calculated over the three most recently filed Medicare cost reports.
Capped Amount: The total amount of both types of payments is capped because payments cannot exceed the
program’s annual appropriation. CHGME recipients are required to report certain information, and amounts
received for DGME under the CHGME program can be reduced by up to 25% for failing to report.
FTE Cap: HRSA determined each participating hospital’s “cap” based on the hospital’s number of ful -time
equivalent residents training as of 1996 (the base year). Hospitals that did not have a “cap” at that time could
receive one by affiliating with another hospital or by beginning a new residency training program. A hospital’s FTE
count reflects the hospital’s number of residents training in the hospital and at certain nonhospital sites
throughout the hospital’s fiscal year. FTE counts may exceed the number of individual residents in a training
program because some periods of a resident’s training may not count for purposes of the cap. As such, the
number of residents a hospital trains generally exceeds its cap.
Payment Processes: Hospitals are paid monthly on an interim basis with amounts withheld to ensure that
hospitals are not overpaid. Final amounts are determined based on hospital cost reports; at that time, payments
are adjusted, and any overpayment to a hospital is expected to be returned.
Source: CRS Analysis of 42 U.S.C. §256(e)(c) and 42 U.S.C. §256(e)(d).
Despite similarities in the structure of Medicare GME and CHGME payments, there are two
noteworthy funding differences between the two programs and a third difference in the reporting
requirements for the two programs. First, the CHGME program is a discretionary program, with
funds drawn from the Treasury. Congress must appropriate funds annually in order for hospitals
to receive CHGME payments. In contrast, Medicare GME payments are mandatory and are
drawn from the Medicare trust funds.24 As a result, Medicare GME funds do not need to be
appropriated annually and do not need to be reauthorized.
A second difference is that CHGME spending is limited by the size of the annual appropriation.
Given this, if CHGME appropriations do not increase, adding new hospitals to the program would
result in a reduction in the amount of funds that existing hospitals receive.25 Conversely,
Medicare GME funds flow to a hospital based on the size of its approved residency training
programs, the number of Medicare-recognized residents, and its Medicare inpatient volume.
Distributing Medicare GME funds to one hospital does not affect the Medicare GME funds paid
to another.
A third difference between Medicare GME and the CHGME program is that, in statute, hospitals
that receive CHGME support are required to report to HRSA the number of residents they train
by specialty; such hospitals may be penalized—in the form of reduced DGME payments—for
failure to report. In contrast, the Center for Medicare & Medicaid Services (CMS)—which
administers the Medicare program—does not require its programs to report data on the trainees

24 GME funds are drawn from the Medicare Part A (Hospital Insurance) trust fund.
25 This constraint means that adding new hospitals or hospital types to the program may reduce existing funding
available to children’s hospitals that currently participate in the program. It would also mean that hospitals that seek to
expand their training programs by adding residents could result in lower levels of support per resident at other
CHGME-supported hospitals.
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supported with Medicare funds.26 Additionally, HRSA is required by the CHGME statute to
aggregate the data it receives from GME programs and report on
1. the types of residency training programs (by specialty);
2. the number of residents supported in each specialty;
3. the training programs that hospitals operate that provide care to diverse and
underserved children;
4. changes in training programs from the prior year (including curricula changes);
and
5. the number of graduates of a hospital’s residency training programs that practice
within the service area where they trained.27
CMS does not have similar reporting requirements for Medicare GME, nor does CMS generally
collect the component data that would be required to compile such a report.28 The 2013 CHGME
reauthorization also included authorization for a quality bonus system, whereby hospitals that
meet established standards are eligible for additional payments. This represents the first system
within a federal GME payment program where payments are distributed based on hospitals
reporting certain data and having programs that meet certain established goals.29 No similar
system exists for Medicare GME payments; however, expert groups, including the Institute of
Medicine (now National Academy of Medicine), recommend that some Medicare GME be
awarded based on program performance.30
CHGME Quality Bonus System
The CHGME Quality Bonus System (QBS) aims to incentivize hospitals to report individual-
level data on residents.31 In statute, the program authorizes the Secretary to establish a QBS for
hospitals that meet standards specified by the Secretary in areas such as quality measures and

26 Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services;
Institute of Medicine, Graduate Medical Education That Meets the Nation’s Health Needs, ed. Jill Eden, Donald
Berwick, and Gail Wilensky (Washington, DC: National Academies Press, 2014).
27 42 U.S.C. §256(e)(b)(2)(B).
28 The lack of data on the residents supported with Medicare GME payments has been raised as a critique of the
program by a number of expert groups. For example, the Government Accountability Office has recommended better
data collection in a series of reports. See U.S. Government Accountability Office, Physician Workforce: HHS Needs
Better Information to Comprehensively Evaluate Graduate Medical Education Funding
, 18-240, March 9, 2018 and
see U.S. Government Accountability Office, Health Care Workforce: Comprehensive Planning by HHS Needed to
Meet National Needs
, 16-17, December 11, 2015.
29 U.S. Department of Health and Human Services, FY2022: Health Resources and Services Administration:
Justification of Estimates for Appropriations Committee” https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2022.pdf, pp. 175-176.
30 Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services;
Institute of Medicine, Graduate Medical Education That Meets the Nation’s Health Needs, ed. Jill Eden, Donald
Berwick, and Gail Wilensky (Washington, DC: National Academies Press, 2014). In 2017, the National Academies
convened a workshop to discuss GME outcome metrics, including the quality of training that programs provide and the
quality of care provided by residents. See Board on Health Care Services, Health and Medicine Division, The National
Academies of Sciences, Engineering, and Medicine, Graduate Medical Education Outcomes and Metrics: Proceedings
of a Workshop, Payal Martin, Mariana Zindel, and Sharyl Nass, Rapporteurs (Washington, DC: National Academies
Press, 2018).
31 U.S. Department of Health and Human Services, FY2022: Health Resources and Services Administration:
Justification of Estimates for Appropriations Committee” https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2022.pdf, pp. 175-176.
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improvement.32 In practice, the system requires reporting on resident-level characteristics as
discussed below. Hospitals began reporting under this system in FY2019, with hospitals initially
reporting information about their trainees. Based on these reports in FY2020 and FY2021, a
subset of hospitals received bonus payments—29 of 59 hospitals in FY2020.33 Since that time all
participating hospitals (59) received these payments, in academic year (AY) 2021-2022 by
completing individual level documentation of all the residents that the program supported.34 The
FY2023 CHGME FY2023 Notice of Funding Opportunity required that hospitals submit the
following data as part of their annual performance report to be eligible for award payments and
meet the following data collection metrics:
• individual level data for all residents supported in FY2023;
• have a 90% or greater response rate on resident’s demographic characteristics,
including their ethnicity, race, rural and disadvantaged background and at the
same response rate on residency training in telehealth and working on
interprofessional teams; and
• have a 50% or greater response rate on post-residency employment of residents
who completed their training.35
CHGME Eligible Hospitals and
Payment Distribution
As discussed above, the CHGME program provides GME funds to free-standing children’s
hospitals. According to HRSA, when the program first began in FY2000, there were 60 hospitals
eligible. In FY2001, the program supported residents training at 57 of these 60 hospitals.36 In
FY2022, the most recent year of final data available, the program supported training at 59 free-
standing children’s hospitals located in 29 states, the District of Columbia, and Puerto Rico.37
(See the Appendix for a list of hospitals that received CHGME and the amount of payments they
received.)

32 42 U.S.C. §256e(h)(6).
33 U.S. Department of Health and Human Services, FY2022: Health Resources and Services Administration:
Justification of Estimates for Appropriations Committee, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2022.pdf, pp. 175-176.
34 The U.S. Department of Health and Human Services, FY2024: Health Resources and Services Administration:
Justification of Estimates for Appropriations Committee, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2024.pdf, pp. 175.
35 U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health
Workforce, Division of Medicine and Dentistry, “Children’s Hospital Graduate Medical Education (CHGME) Payment
Program,” Funding Opportunity Number: HRSA-23-012.
36 U.S. Department of Health and Human Services, Health Resources and Services Administration, Justification of
Estimations for Appropriations Committees, FY2004, Rockville, MD.
37 The U.S. Department of Health and Human Services, FY2024: Health Resources and Services Administration:
Justification of Estimates for Appropriations Committee, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2024.pdf, pp. 175, and CRS analysis of information in Table A-1. Hospitals in the following 21
states did not have hospitals that received CHGME payments in FY2022: Alaska, Idaho, Iowa, Indiana, Kansas,
Kentucky, Maine, Mississippi, Montana, New Hampshire, New Mexico, Nevada, North Carolina, North Dakota,
Oklahoma, Oregon, South Carolina, South Dakota, Vermont, West Virginia, and Wyoming. See Health Resources and
Services Administration, Children’s Hospital Graduate Medical Education Program, Program Data, at
https://bhw.hrsa.gov/funding/children-hospitals-graduate-medical-education-awardee-map. In prior years, hospitals in
New Mexico and South Carolina have received CHGME funding.
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More than half of states have an eligible free-standing children’s hospital that receives CHGME
payments. These states are geographically dispersed. Residents in states with no CHGME-funded
hospitals may benefit from the program by traveling to receive services at a CHGME-supported
hospital or by receiving treatment from a pediatrician or a pediatric subspecialist who trained at
one. The extent to which this occurs is unknown.
The 10 states receiving the highest amount of CHGME payments in FY2020 were generally
states with large populations. Among the 10 states, all had at least one large children’s hospital
that received more than $5 million annually in CHGME payments (e.g., Children’s Hospital of
Philadelphia in Pennsylvania and Boston Children’s Hospital in Massachusetts). Table 2 presents
the 10 states that received the highest payment amounts under this program.
Table 2. Children’s Hospital GME Funding in FY2022, by State
Number of
Hospitals Receiving
State Name
Payments
Funding Level
Rank
California
7
$50.6 mil ion
1
Pennsylvania
3
$47.9 mil ion
2
Ohio
6
$36.0 mil ion
3
Texas
7
$32.9 mil ion
4
Massachusetts
2
$24.0 mil ion
5
Washington, DC
1
$15.8 mil ion
6
Missouri
2
$14.8 mil ion
7
Michigan
1
$13.9 mil ion
8
Il inois
2
$11.6 mil ion
9
Washington
2
$10.4 mil ion
10
Source: CRS Analysis of grant data, downloaded from https://data.hrsa.gov/data/download.
Notes: For the purposes of this table, the District of Columbia is included as a state. Were it to be excluded,
the state where hospitals received the next highest CHGME payment (following Washington) would have been
Florida ($10.3 mil ion awarded to three hospitals).
CHGME Residents Trained
Table 3
presents the number of residents that received CHGME support since the program’s
inception in FY2000. The number of residents trained has steadily increased, but the program’s
appropriation has varied over time. Given this, the amount of funding awarded to support each
individual resident has also varied. In addition, the table shows that the number of hospitals that
participate in the program has fluctuated over time; in some years, CHGME funds are awarded to
fewer hospitals that, on average, are training more residents. Note that the 2013 reauthorization
added new hospitals to the program, but it reserved a portion of the program’s appropriation for
these new hospitals to mitigate decreases in payment amounts for hospitals that were already
participating in the program.
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Table 3. Number of Residents Trained and Hospitals Receiving CHGME Awards
FY2000-FY2024 (proposed)
Number of
Number of
Appropriation
Fiscal Year
Residents Trained
Hospitals
(in millions)
FY2000
4,820
55
$40.0
FY2001
4,665
59
$235.0
FY2002
4,303
60
$284.9
FY2003
N/Aa
61
$290.1
FY2004
4,892
61
$303.2
FY2005
5,103
61
$307.7
FY2006
5,243
60
$296.8
FY2007
5,406
57
$297.0
FY2008
5,600
56
$301.6
FY2009
5,840
56
$310.0
FY2010
6,040
55
$316.8
FY2011
6,185
55
$268.4
FY2012
6,015
55
$265.2
FY2013
6,535
54
$251.2
FY2014
6,698
54
$264.3
FY2015
6,877
57
$265.0
FY2016
7,164b
58
$294.3
FY2017
7,367c
58
$299.3
FY2018
7,522d
58d
$314.2
FY2019
7,757e
58
$323.4
FY2020
7,900f
59
$340.0
FY2021
8,224g
59
$349.0
FY2022
N/Ah
59h
$375.0
FY2023
N/Ai
59i
$385.0
FY2024
N/A
Proposed 59
Proposed $385.0
Source: N/A = available. CRS Analysis of Congressional Justifications FY2000-FY2024 from the Health
Resources and Services Administration. See U.S. Department of Health and Human Services, “Budgets in Brief
and Performance Reports,” https://www.hhs.gov/about/agencies/asfr/budget/budgets-in-brief-performance-
reports/index.html, and Department of Health and Human Services, Health Resources and Services
Administration, About HRSA, “Budget,” for more recent budget years.
a. HRSA budget documents did not include these data.
b. HRSA began using the academic year (i.e., July 1 through June 30) for its CHGME data in the FY2017 HRSA
budget justification, which included data for academic year 2015-2016.
c. Academic Year 2016-2017 data.
d. Academic Year 2018-2019.
e. Academic Year 2019-2020.
f.
Academic Year 2020-2021.
g. Academic Year 2021-2022.
h. Academic Year 2021-2022, data for the number of residents trained in this period were not available as of
publication.
i.
Academic Year 2022-2023, data for the number of residents trained in this period were not available as of
publication.
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Other Sources of GME Funding for
Children’s Hospitals
CHGME funds are one source of medical residency training support at children’s hospitals. Other
sources exist, including patient care or other revenue, Medicaid, state and local funds, and private
donations.38 However, CHGME payments are the only source for which a specific amount can be
quantified.
Some have suggested that the availability of other sources of GME funding lessens, or obviates,
the need for the CHGME program. For example, the Office of Management and Budget in a 2003
CHGME Program Assessment stated that the program was performing adequately, but noted that
the program is “fundamentally duplicative of other Federal, state, and private efforts.”39 The
assessment went on to say that children’s hospitals have higher profit margins than other
hospitals, which could lead to more revenue available to support training programs. The
assessment concluded with a recommendation to more closely track the accountability of
children’s hospitals receiving payments under the program and to assess whether the program
should be continued.40
More recent data also indicate that children’s hospitals are still operating at higher profit margins
than other hospital types. These data also suggest that despite these hospitals having tax-exempt
status, some provide little charity care.41 Given that profits in a nonprofit hospital are intended to
be reinvested in the hospital,42 these funds are a potential source of GME support. However, this
research is historical, and it is not clear whether these financial advantages persist. In addition, the
CHGME pays hospitals less per resident than do other sources of GME.43 The Children’s Hospital
Association—the organization the represents children’s hospitals—contends that the program is

38 For a general overview of Medicaid, see CRS Report R43357, Medicaid: An Overview. For information about
Medicaid GME payments, see Medicaid section in CRS Report R44376, Federal Support for Graduate Medical
Education: An Overview
. Some pediatric fellows may conduct research as part of their training program; federal
research grants, including those from the National Institutes of Health (NIH), may offset some or all of the costs
associated with such research, including the fellow’s salary. In this case, while a children’s hospital may receive
research funding to support fellows, the funding would not be for medical training. Information on the total amount of
research funding that children’s hospitals receive, or the percentage of that amount used to support pediatric
subspecialty training, is not available. For more information about NIH research grants in general, see CRS Report
R41705, The National Institutes of Health (NIH): Background and Congressional Issues.
39 ExpectMore.Gov, “Program Assessment: Children’s Hospital Graduate Medical Education Payment Program,” 2003,
http://georgewbush-whitehouse.archives.gov/omb/expectmore/summary/10001063.2003.html.
40 Ibid.
41 Gilbert M. Gaul, “Growing Size and Wealth of Children’s Hospitals Fueling Questions about Spending,” September
25, 2011, Kaiser Health News, http://www.kaiserhealthnews.org/Stories/2011/September/26/Childrens-Hospitals-Part-
One.aspx; and Gilbert M. Gaul, “Nonprofit Children’s Hospitals Get Valuable Tax Exemptions but Many Provide
Little Free Care,” Kaiser Health News, September 25, 2011, http://www.kaiserhealthnews.org/Stories/2011/September/
26/Childrens-Hospitals-Charity-Care.aspx.
42 There have been ongoing issues raised with respect to nonprofit hospitals; see CRS Report RL34605, 501(c)(3)
Hospitals and the Community Benefit Standard
.
43 The Children’s Hospital Association estimates that the program pays on average $79,000 per resident. See
“Comparative Analysis of GME Funding for Children’s Hospitals and General Acute Care Teaching Hospitals,” March
23, 2022, and FY2024 statement Children’s Hospital Association, “Improving Children’s Access to Care: Increase
Funding for CHGME,” March 2023, at FY 2024 CHGME Appropriations Resources (childrenshospitals.org) (see
CHGME/GME Resident Funding Comparison study and FY2024 Supporting Organizations Funding Letter). The
Government Accountability Office estimated that Medicare pays on average $171,000 per resident in 2018. U.S.
Government Accountability Office, Physician Workforce: Caps on Medicare-Funded Graduate Medical Education and
Teaching Hospitals
, 21-391, May 2021, p. 8, https://www.gao.gov/assets/gao-21-391.pdf.
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not paying the full cost of resident training and will disadvantage pediatric training, as these
payments grow at a slower rate than do Medicare GME payments.44 In 2023, the Children’s
Hospital Association along with other advocates noted in a letter to appropriators that the program
pays approximately one-half of the amount that other federal training programs pay per resident.45
Others have examined payments over time and noted that they have not adjusted for inflation.
These researchers contend that the lack of inflation adjustment has resulted in a steady decline in
per-resident amounts; they estimate that the inflation-adjusted average of support per resident was
$39,000 (for the period of 2000 through 2016). This amount was below their estimates of training
costs, which was $72,227 in 2000 dollars and $112,000 in 2021 dollars.46 In contrast, the
estimated amount that Medicare paid per resident in 2018 was an average of $171,000 per
resident, with amounts paid ranging between $68,000 and $279,000 depending on the hospital.47
Despite these differences in amount paid by program, the true “cost” of training residents is
difficult to determine, as it may vary by the type of resident, the year the resident is in training,
the resident’s specialty, and programs’ efficiency among other things.48 Given this complexity, it
is not possible to evaluate whether the CHGME program is paying full resident costs, nor do
systematic data exist on the use of hospital revenue to support GME. Given that these data do not
exist, the Congressional Research Service cannot determine whether, and to what extent, hospitals
use their own revenue to support GME. Despite data showing the impact of the CHGME program
on pediatric residency training, it is not clear whether the pediatric workforce would have
increased without the program’s explicit support, because many of the available funding sources
existed prior to the program’s inception. Similarly, it is not possible to know whether the
increased workforce size could be attributable to training supported by other funding sources
available to children’s hospitals.
Another source of GME funding for children’s hospitals is Medicaid reimbursements, but data are
limited regarding the extent to which these funds are used. Medicaid is a joint federal-state
program in which states operate their own program under federal oversight. States may choose to
use Medicaid funds to support GME, but not all states choose to do so. According to Medicaid
expenditure data, 36 states, including the District of Columbia, reported making Medicaid GME
payments through the fee-for-service delivery system in FY2021,49 and those payments totaled

44 FY2022 statement Children’s Hospital Association, “Improving Children’s Access to Care: Increase Funding for
CHGME to $485 Million for FY2022,” February 2021, https://www.childrenshospitals.org/-/media/Files/CHA/Main/
Issues_and_Advocacy/Key_Issues/Graduate_Medical_Education/Talking_Points/chgme_fy22_talking_points.pdf.
45 Letter from American Pediatrics Association et al. to The Honorable Tammy Baldwin, The Honorable Shelly Moore
Capito, The Honorable Robert Aderholt, The Honorable Rosa DeLauro, Subcommittee Labor, Health, Education and
Related Agencies Chair and Ranking Member, March 2023, https://www.aamc.org/media/66066/download?
attachment.
46 Shetal Shah and Tina L. Cheng, “Optimizing the Children’s Hospital Graduate Medical Education Payment Program
at a Time of Pediatric Workforce Challenges and Health Need,” Pediatrics, vol. 245 (2022), pp. p4-6.E2.
47 U.S. Government Accountability Office, Physician Workforce: Caps on Medicare-Funded Graduate Medical
Education and Teaching Hospitals
, 21-391, May 2021, p. 8, https://www.gao.gov/assets/gao-21-391.pdf.
48 See CRS Report R44376, Federal Support for Graduate Medical Education: An Overview, for an overview of the
complexities related to the costs of training. In addition, the Government Accountability Office found that cost of
resident training estimates ranged from $35,000 per year to $226,000 per year. U.S. Government Accountability Office,
Physician Workforce: Caps on Medicare-Funded Graduate Medical Education and Teaching Hospitals, 21-391, May
2021, p. 7, https://www.gao.gov/assets/gao-21-391.pdf.
49 Under the FFS delivery system, health care providers are paid by the state Medicaid program for each service
provided to a Medicaid enrollee. Under the managed care delivery system, Medicaid enrollees get some or all of their
services through an organization under contract with the state. For more information on Medicaid managed care, see
CRS Report R43357, Medicaid: An Overview.
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$3.4 billion, with the federal government paying 66% of that amount.50 These expenditure data
include only fee-for-service GME payments, but states can also make Medicaid GME payments
through Medicaid managed care.51
Concluding Observations
Appropriations for the CHGME program were reauthorized in 2018 through the end of FY2023.
Though the reauthorization did not include substantive changes, the program’s unique reporting
requirements and quality bonus system, which has been implemented since that reauthorization,
may be of congressional interest given concerns about accountability in federal GME funding.
The CHGME program collects and reports a number of data elements on the residents trained.
This differs from other and larger sources of federally supported GME program (e.g., Medicare).
As such, the CHGME program data may be useful for Congress to examine to determine whether
such data are sufficient and whether it would be useful for other programs to collect such data
elements. The CHGME program has also implemented a quality bonus system that provides
additional payments to programs that provide data. In FY2022, all eligible hospitals reported the
required information (see “CHGME Quality Bonus System”), as such, Congress may evaluate
whether these payments, which effectively reward reporting are functioning as intended, which
would be to reward quality training, rather to provide extra payments to all programs as occurred
in FY2022, the last year of complete data. Despite this potential concern, the Quality Bonus
System is unique among federal GME programs and is in line with the recommendations of
expert groups (e.g., the Institute of Medicine).52 As such, this system and whether any potential
refinements are needed may be an area for future congressional oversight. Further, Congress may
consider whether part of this reporting system could be applied to other GME programs.

50 States submit the CMS-64 form to the Centers for Medicare & Medicaid Services on a quarterly basis to the
Medicaid Budget and Expenditure System, and the CMS-64 form is a statement of expenditures for which states are
entitled to federal Medicaid matching funds. According to CRS analysis of CMS-64 data, Delaware and Kansas had
negative Medicaid GME payments in FY2021 that may have been due to prior period adjustments.
51 States are able to make Medicaid GME payments under Medicaid managed care. (42 C.F.R. § 438.60) Recent data
for Medicaid GME payments made under managed care are not publicly available. However, in FY2018, 16 states,
including the District of Columbia, made Medicaid GME payments under managed care directly to a teaching hospital
or other teaching entity. (Tim M. Henderson, Medicaid Graduate Medical Education Payments: Results from the 2018
50-State Survey, Association of American Medical Colleges, Washington, DC, July 2019, https://store.aamc.org/
downloadable/download/sample/sample_id/284/)
52 Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services and
Institute of Medicine, Graduate Medical Education That Meets the Nation’s Health Needs, ed. Jill Eden, Donald
Berwick, and Gail Wilensky (Washington, DC: National Academies Press, 2014). The Institute of Medicine is now
called the National Academy of Medicine.
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Appendix. Children’s Hospitals that
Received CHGME
Table A-1
presents the most recent data on hospitals that participate in the program, the state in
which they are located, and the amount of CHGME funding they received.
Table A-1. Children’s Hospitals that Received CHGME Support, FY2000-FY2022
(in millions of dollars, alphabetical by state or territory)
Name of
State/
FY2000-
FY2011-
FY2016-
FY2000-
Hospitala
Territory
FY2010
FY2015
FY2020
FY2021
FY2022
FY2022
Children’s
AL
$55.88
$21.06
$27.17
$5.93
$6.29
$116.33
Hospital of
Alabama
University of
AL
$19.35
$12.17
$14.30
$3.62
$3.78
$53.22
South Alabama
Children's
Arkansas
AR
$74.42
$32.60
$38.04
$8.32
$9.62
$163.00
Children’s
Hospital
Phoenix Children's
AZ
$18.29
$8.85
$14.00
$3.19
$3.67
$48.00
Hospital, Inc.
Children's
CA
$0.00
$6.51
$12.48
$2.80
$3.34
$25.13
Healthcare of
California
Children's
CA
$75.80
$34.09
$43.11
$9.45
$10.29
$172.74
Hospital &
Research Center
at Oakland
The Children’s
CA
$100.49
$18.29
$14.29
$14.96
$16.65
$164.68
Hospital of Los
Angeles
Long Beach
CA
$33.97
$17.35
$19.56
$4.65
$5.09
$80.62
Memorial Medical
Center
Lucile Salter
CA
$62.27
$31.84
$41.82
$9.25
$9.39
$154.57
Packard Children’s
Hospital at
Stanford
Rady Children’s
CA
$39.84
$19.27
$22.07
$4.84
$5.16
$91.18
Hospital-San
Diego
Valley Children’s
CA
$6.94
$2.87
$2.88
$0.64
$0.68
$14.01
Hospital
Children’s
CO
$68.90
$30.88
$33.76
$7.99
$9.12
$150.65
Hospital Colorado
Connecticut
CT
$37.07
$13.52
$15.03
$3.48
$3.66
$72.76
Children’s Medical
Center
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Name of
State/
FY2000-
FY2011-
FY2016-
FY2000-
Hospitala
Territory
FY2010
FY2015
FY2020
FY2021
FY2022
FY2022
Children’s
DC
$127.26
$58.72
$64.08
$14.74
$15.79
$280.59
National Medical
Center
The Nemours
DE
$35.82
$14.79
$19.60
$4.06
$4.05
$78.32
Foundations
Johns Hopkins All
FL
$28.65
$10.00
$12.46
$2.57
$2.64
$56.32
Children’s
Hospital, Inc.
The Nemours
FL
$0.00
$0.00
$1.36
$1.31
$1.76
$4.43
Foundation
Variety Children’s
FL
$54.84
$22.81
$27.80
$5.44
$5.92
$116.81
Hospital
Egleston
GA
$50.36
$22.37
$28.81
$5.94
$6.33
$113.81
Children’s
Hospital at Emory
University, Inc.
Scottish Rite
GA
$8.12
$5.33
$4.97
$1.03
$1.15
$20.60
Children’s Medical
Center, Inc.
Kapiolani Medical
HI
$34.21
$17.14
$20.99
$4.40
$4.79
$81.53
Center for
Women and
Children
Ann & Robert H.
IL
$93.72
$41.15
$52.67
$11.28
$11.47
$210.29
Lurie Children’s
Hospital of
Chicago
La Rabida
IL
$2.41
$0.87
$0.85
$0.13
$0.14
$4.40
Children’s
Hospital
Children’s
LA
$32.53
$21.03
$25.72
$6.08
$6.89
$92.25
Hospital
The Children’s
MA
$213.88
$88.93
$107.00
$22.66
$23.73
$456.20
Hospital
Corporation
Franciscan
MA
$0.21
$0.79
$1.32
$0.30
$0.27
$2.89
Hospital for
Children, Inc.
Kennedy Krieger
MD
$2.74
$1.21
$1.81
$0.37
$0.33
$6.46
Children's
Hospital, Inc.
VHS Children’s
MI
$135.78
$57.83
$63.52
$14.15
$13.85
$285.13
Hospital of
Michigan, Inc.
Children's
MN
$0.00
$8.48
$18.11
$4.02
$3.90
$34.51
Healthcare
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Name of
State/
FY2000-
FY2011-
FY2016-
FY2000-
Hospitala
Territory
FY2010
FY2015
FY2020
FY2021
FY2022
FY2022
Gil ette Children’s
MN
$4.88
$3.02
$3.12
$0.73
$0.70
$12.45
Specialty
Healthcare
Children’s Mercy
MO
$62.29
$24.70
$28.83
$6.72
$7.02
$129.56
Hospital
St. Louis
MO
$71.88
$28.21
$33.80
$7.21
$7.75
$148.85
Children’s
Hospital
Children’s
NE
$9.21
$4.20
$6.01
$1.34
$1.34
$22.10
Hospital
Children’s
NJ
$0.52
$0.22
$0.30
$0.03
$0.03
$1.10
Specialized
Hospital
Blythedale
NY
$0.73
$0.40
$0.40
$0.05
$0.07
$1.65
Children’s
Hospital, Inc.
Children’s
OH
$112.89
$46.81
$53.42
$11.76
$12.86
$237.74
Hospital Medical
Center
Children’s
OH
$35.83
$14.45
$16.73
$3.67
$4.07
$74.75
Hospital Medical
Center of Akron
The Cleveland
OH
$0.29
$0.16
$0.16
$0.03
$0.03
$0.67
Clinic Foundation
Dayton Children’s
OH
$29.21
$12.69
$14.82
$3.09
$3.90
$63.71
Hospital
Nationwide
OH
$85.35
$34.89
$37.31
$8.67
$8.90
$175.12
Children’s
Hospital
University
OH
$51.79
$19.86
$24.08
$5.39
$6.21
$107.33
Hospital/Cleveland
Medical Center
The Children’s
PA
$209.00
$87.61
$108.45
$25.12
$26.17
$456.35
Hospital of
Philadelphia
Children’s
PA
$92.15
$43.34
$51.29
$11.71
$13.12
$211.61
Hospital of
Pittsburgh
STC OPCO, LLCb
PA
$67.53
$40.21
$47.27
$9.19
$8.58
$172.78
Department of
PR
$17.90
$6.96
$8.46
$1.47
$1.60
$36.39
Health
Emma Bradley
RI
$0.00
$0.29
$1.54
$0.29
$0.30
$2.42
Pendleton
Hospital
St. Jude Children’s
TN
$13.22
$5.13
$6.67
$1.46
$1.76
$28.24
Research Hospital
Ascension Seton
TX
$0.00
$0.00
$4.30
$2.51
$2.83
$9.64
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Name of
State/
FY2000-
FY2011-
FY2016-
FY2000-
Hospitala
Territory
FY2010
FY2015
FY2020
FY2021
FY2022
FY2022
Children's Health
TX
$0.00
$0.00
$7.07
$7.14
$10.03
$24.24
Clinical
Operations
Christus Santa
TX
$6.98
$0.00
$5.77
$1.95
$2.56
$17.26
Rosa Health Care
Corporation
Cook Children’s
TX
$1.45
$0.54
$0.64
$0.16
$0.14
$2.93
Medical Center
Driscol Children’s
TX
$19.47
$7.50
$8.51
$1.88
$2.09
$39.45
Hospital
El Paso Children’s
TX
$0.00
$1.05
$6.26
$1.31
$1.48
$10.10
Hospital
Corporation
Texas Children’s
TX
$108.70
$46.70
$57.05
$12.75
$13.72
$238.92
Hospital
Intermountain
UT
$55.13
$24.66
$28.98
$6.76
$6.94
$122.47
Health Care, Inc
Children’s
VA
$30.86
$9.64
$13.81
$3.26
$3.62
$61.19
Hospital of the
King’s Daughters,
Inc.
Multicare Health
WA
$2.50
$1.41
$1.53
$0.37
$0.35
$6.16
System
Seattle Children’s
WA
$95.85
$42.48
$48.51
$9.74
$10.03
$206.61
Hospital
Children’s
WI
$90.12
$35.60
$37.16
$8.48
$8.67
$180.03
Hospital of
Wisconsin, Inc.
Total
$2,689.48
$1,163.48
$1,411.83
$331.84
$356.62
$5,953.25
Source: CRS Analysis of grant data downloaded from https://data.hrsa.gov/data/download.
a. In a number of cases, hospital names have changed over the time period. In these cases, the name listed in
HRSA’s FY2022 grant data is used.
b. STC OPCO, LLC was previously St. Christopher’s Healthcare, LLC. There were two values for STC
OPCO, LLC in FY2020, which represented the closure and transition of funds from St. Christopher’s to
STC OPCO, LLC.

Author Information

Elayne J. Heisler

Acting Section Research Manager

Congressional Research Service

18

Children’s Hospitals Graduate Medical Education (CHGME)


Acknowledgments
Emma C. Nyhof and Kenneth Fassel, former CRS Research Assistants, and John H. Gorman, CRS
Research Assistant, provided valuable assistance preparing the tables and figures included in this report.
Michele Malloy, CRS Research Librarian, provided research support for this report. Alison Mitchell, CRS
Specialist in Health Care Financing, assisted with the Medicaid GME financing content in this report.

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
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copy or otherwise use copyrighted material.

Congressional Research Service
R45067 · VERSION 10 · UPDATED
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