A Guide to Graduate Medical Education Funding in California

University of California, San Francisco
The Robert Graham Center


California’s diverse population — the biggest in the United States — is growing. The state has an urgent need to train a modern health care workforce with the skills required to provide care in a rapidly evolving environment. Physicians develop those skills from graduate medical education (GME), which is a period of residency and fellowship training undertaken after graduation from a school of allopathic or osteopathic medicine. GME is a vital pipeline.

A Guide to Graduate Medical Education Funding in California explores the funding behind GME in California. It seeks to describe the institutions and bodies that provide funding, and how they allocate funds, where they do their work, and which types of residencies they approve. Overall, it offers a view into a complex and deeply fragmented system of subsidies that could have a tremendous impact on the future of California’s health care workforce.

Key takeaways include:

  • There is no centralized state or federal planning for how GME resources are allocated and no single point of accountability for GME outcomes.
  • The Centers for Medicare & Medicaid Services (CMS) is by far the largest payer for GME, but it lacks transparency and is based on antiquated formulas that are not related to actual GME costs.
  • On a per capita basis, CMS has continually underfunded GME in California relative to other states.
  • Medi-Cal payments to hospitals no longer have dedicated funds for GME, but instead are in the the form of supplemental payments that can be used at the discretion of the hospital.
  • California’s innovative Song-Brown program supplements primary care GME funding, but the program is small and dependent on the state’s budgeting process.
  • Proposition 56 was intended to provide substantial new funding for GME but the money has not been allocated as intended.

The slideshow below highlights six key points from the paper.

The full guide and the slideshow slides are available to download under Related Materials. This paper was authored by Diane Rittenhouse, MD, Alexandra Ament, and Kevin Grumbach, MD, of the University of California, San Francisco, and Stephen Petterson, PhD, Zachary Levin, and Andrew Bazemore, MD, MPH, of the Robert Graham Center.