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VA Funding of Graduate Medical Education

VA Funding of Graduate Medical Education. August 28, 2010 Family Medicine Working Grooup Barbara K. Chang, MD, MA VHA Office of Academic Affiliations. VA Milestones. Veterans Administration established as an independent federal agency on July 21, 1930.

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VA Funding of Graduate Medical Education

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  1. VA Funding of Graduate Medical Education August 28, 2010 Family Medicine Working Grooup Barbara K. Chang, MD, MA VHA Office of Academic Affiliations

  2. VA Milestones • Veterans Administration established as an independent federal agency on July 21, 1930. • Department of Veterans Affairsbecame cabinet level on March 15, 1989. • Veteran's Health Care Eligibility Reform Act of 1996 (PL 104-262) • Veterans Millennium Health Care and Benefits Act of 1999 (PL 106-117) 2

  3. Partnership with Academic Medicine Policy Memorandum No 2. Establishing Teaching Affiliations Subject: Policy in Association of Veterans’ Hospitals with Medical Schools January 30, 1946 3

  4. Veterans Health Administration (VHA) • Largest integrated healthcare system in US (FY 09 data): • VA Hospitals: 153 • Outpatient Clinic Total: 956 • Hospital Based Outpatient Clinics (HBOC) 153 • Independent Outpatient Clinics (IOC) 6 • Mobile Outpatient Clinics (MOC) 9 • Community Based Outpatient Clinics (CBOC) 788 • 8 M enrollees • 5.1 M patient treated annually • ~200K FTE employees (~65K health care, including ~17K physicians) 4

  5. Overview: VA Trainee ‘Workforce’ • ~100K trainees annually • GME & UME – about 50% • Associated health education (40K+) • Advanced (non-accredited) fellowships • Annual budget • ~$0.6B (direct costs) & $0.6B (indirects) • 80% devoted to GME • 2nd only to CMS (Medicare & Medicaid) in support of GME 5

  6. GME Scope in VA >36,000 residents rotate through 124 of 153 VA Hospitals & 2/6 IOCs representing 1/3rd all US residents representing 37% VA physician workforce 60% VA staff physicians are former trainees Affiliations with 107 of 129 US allopathic & 15 of 26 osteopathic medical schools 6

  7. Scope of GME in VA • >36,000 physician residents – representing ~30% of all US residents – receive training in VA annually • 2,000+ ACGME-accredited programs • Representing 79 different medical specialties & subspecialties • Prior to GME Enhancement, VA supported about 8,900 individual resident salary lines (8.5% of US) – now about 10K slots • 99%of VA programs are sponsored in the name of affiliates 7

  8. VA’s Transformative Initiatives: Pt.Centered Primary Care • New Model: • Patient-Centric/Team-Based • Active collaboration & communication among team inclusive of patient/family throughout workflow Patient Engagement Patient Preference Shared Decision-Making • Current Model: • Provider/Professional-Centric • CPRS Facilitates mostly “Do” Actions CPRS 8 8

  9. VA involvement in Internal Medicine – ~3,300 positions in AY 10-11 9

  10. VA involvement in Family Medicine:Ten-year history 10

  11. VA involvement in Family Medicine – ~100 positions in AY 10-11 11

  12. VA involvement in Family Medicine – ~100 positions in AY 10-11 12

  13. How does VA fund GME positions? • Annual resident allocation cycle • Base (permanent) positions apply for in October & approved by early Dec. in time for Match (NRMP) • Filled positions allocated post-Match (mid-to late March report) – final approvals, early May • Temporary positions may be available if unfilled • Historic 'base' vs. current needs • Requires a planning process – with GMEC • Involvement of the DIO, the Program Director, the VA Site Director, & the VA Designated Education Officer (DEO) 13

  14. What GME activities can VA fund? • Resident educational activities while on assignment to the VA • Clinical, didactic & scholarly activities • Cannot fund off-site activities, except for didactic and continuity clinics if reciprocal plus a few other exceptions • Accredited programs & training years • i.e.,non-accredited programs & years may not be funded • However, VA can fully fund accredited fellowship years, unlike Medicare 14

  15. VA vs. Medicare: Summary Comparison *Requires significant paperwork. Healthcare reform legislation may facilitate. **Reciprocal funding of continuity clinics; ‘educational details’ possible for training required by ACGME, but not available at any participating hospital. 15

  16. Indirect Costs • VA: VERA Educational supplement • Currently $71.2K/physician resident - as surrogate for all trainees • Goes to the VISN (most say they ‘pass through’) • Medical care funds – not ‘ear-marked’ • VA: cannot pay indirect costs to affiliates via disbursement agreement • Medicare IDC (indirect costs) • Go to the hospital sponsor to offset medical care costs of teaching hospital (sicker patients, etc.) • Medicare DSH (disproportionate share) • Goes to teaching hospitals with higher % indigent patients • NOTE: neither Medicare nor VA directly funds true indirect costs of education 16

  17. VA GME Payment Mechanisms • Direct salary payment - doesn't work well with rotating residents • Disbursement Agreements • Statutory authority to pay residents stipends & benefits indirectly under disbursement agreements • Must have an affiliation agreement • New disbursement agreement • Planning process & good communication with affiliates is key 17

  18. Revised Policy: Underlying philosophy • Resident positions within approved allocations should be reimbursed to the extent that assigned residents engage in VA-approved educational activities • VA is not paying for residents’ “service” or “work”, but is participating in support of their training • Still cannot fund administrative support of resident programs through disbursement agreements 18

  19. Policy Definitions 19

  20. Accounting for residents who are less than fully-assigned to the VA “Full-time/part-time” designations are now considered as: • “Full”, where the primary assignment is to the VA & no other institution • “Split” assignment, if a resident’s activities are divided between the VA & another participating institution • Sample activity schedules (by program) are to be reviewed by the Program Director & VA Site Director, who decides on the % at the VA, based upon the total activity of the resident – VA DEO concurs 20

  21. Background • History: Federally Chartered Advisory Committee recommendations and approval by the VA Secretary (fall 2005) • 5-year initiative to restore VA-funded positions to historic levels of 10-11% of US total physician resident positions • ~2,000 new positions to be added to the 8,900 pre-existing positions over 5 years • Estimated cost of about $0.25B • RFP process begun 2006 for AY 2007-08 • First major expansion of VA GME in >15 yrs 21

  22. Goals of VA’s GME Enhancement • To address physician workforce shortages • by expanding resident positions in specialties of greatest need to US veterans and the Nation • To address the uneven geographic distribution of residents • to improve access to care • To foster innovative models of education • while enhancing VA’s leadership role in US GME • Add about 2,000 additional resident positions • To a base of about 8,900 in AY 2005-06 – goal of national share 10-11% 22

  23. Allocation Methodology • Competitive application process in response to RFPs (local VA to OAA) • Proposals evaluated on: • Quality of the training experience • Peer review panel of VHA GME experts ranked applications against criteria • Capacity to train • Patient care services delivered by residents 23

  24. 4 GME Enhancement RFPs • Critical Needs & Emerging Specialties (2006 – present) • Facility-identified needs • Facilities w/ ≥ 40 residents eligible • New Affiliations & New Sites of VA Care (2006 – present) • New hospitals or affiliations, OPCs, & Community-based Outpt Clinics (CBOCs) • Educational Innovation (since 2007 – present) • Innovative approaches to education & care delivery – exemplary accreditation status • Rural Health Training (2009) • Trainees in rural or highly rural sites 24

  25. Overall Outcomes: Phases 1-4 (2006-09) • 1,221 Positions added • 71 different specialties • 1,106 programs • 87 VA facilities • Phase 4 only: • 254 GME positions @ 49 facilities (277 requested by 51 facilities) • 15 AH positions (7 EI, 8 RHT) 25

  26. Impact of GME Enhancement 26 26

  27. Approved Resident positions by RFP 27

  28. Shift of Approval to “New Sites” 28

  29. Distribution by Specialty Grouping: GME Enhancement New Positions 31

  30. % Distribution of TOTAL VA positions at baseline & post-GME Enhancement 32

  31. Impact of GME Enhancement onTotal Allocations of Pipeline, Fellowship, & Specialty Positions 33

  32. Common Foci: Educational Innovation • Patient-centered care • Patient safety & QI • Interdisciplinary or “collaborative” care • Continuity of care • Greater ambulatory care • Chronic care management • Simulation • Telemedicine • Competency/proficiency • Professionalism 34

  33. Summary/Conclusions • VA is attempting to expand & change GME to meet the needs of VA & the US • Our emphasis is on educational quality & capacity to train • Geographic distribution has favored the under-represented areas in GME • Challenges: • to impact entry-level positions (in pipeline programs), esp in GIM & • to introduce more innovation into educational programs 35

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