Geographic and Program Size Disparities in Medicare Funding for Graduate Medical Education

Background Medicare direct graduate medical education (DGME) payments are essential to sustaining residency training and shaping the physician workforce. While geographic variation in total DGME spending is well described, less is known about inequities in per-resident funding across states and program sizes. Objective The objective of this article was to assess variation in Medicare DGME payments per resident across US states and residency program sizes and identify patterns relevant to equitable graduate medical education (GME) funding. Methods In 2025, we conducted a retrospective cross-sectional analysis of publicly available Medicare DGME payment data from 2014-2024. All US hospitals reporting DGME payments were eligible (N = 447), with 439 hospitals included (98.2%). Hospitals were stratified by state and residency program size: small (0-20 residents), mid-sized (21-200), and large (>200). The primary outcome was DGME payment per resident. Comparisons were performed across states and program sizes. Sensitivity analyses evaluated resident count and hospital bed capacity. Results Per-resident DGME payments varied significantly by state and program size (p<0.001). The national median payment was approximately $22,000 per resident, with the highest payments in Mississippi and the lowest in California. Small programs received higher mean per-resident payments than mid-sized programs (p<0.01). Hospitals in the highest and lowest payment deciles were concentrated within specific states. Resident count was a stronger predictor of per-resident payments than hospital bed capacity (p<0.001). Conclusions Substantial geographic and program-size-related inequities in per-resident DGME funding persist nationwide. This may disadvantage mid-sized and underserved programs and should be considered in promoting equitable training and workforce distribution.