Clinical Review

A Year 3 Progress Report on Graduate Medical Education Expansion in the Veterans Choice Act

The VA has made progress in implementing mandates to expand medical residency programs to more rural and underserved locations and to increase access to family care providers, but some specialties, like geriatrics, remain underrepresented.

Fed Pract. 2018 February;35(2):22-27

Author(s):

Anthony P. Albanese, MD

Jemma Ayvazian, DNP

Edward Bope, MD

Amanda Van Gilder, MA

Christopher Pelic, MD

Karen Sanders, MD

Monica Lypson, MD

Christyann Clary, MSW

Kathleen Klink, MD

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References

1. U.S. Department of Veteran Affairs. Policy Memorandum No. 2. Policy in association of veterans’ hospitals with medical schools. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf. Published January 30, 1947. Accessed December 13, 2017.

2. U.S. Department of Veteran Affairs, Office of Academic Affiliations. 2017 statistics: health professions trainees. https://www .va.gov/OAA/docs/OAA_Statistics.pdf. Accessed January 8, 2018.

3. IHS, Inc. The complexities of physician supply and demand 2016 update: projections from 2014 to 2025, final report. https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf. Published April 5, 2016. Accessed December 13, 2017.

4. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med. 2015;13(2):107-114.

5. Holder KA. Veterans in rural America 2011-2015. https://www.census.gov/content/dam/Census/library/publica tions/2017/acs/acs-36.pdf. Published January 2017. Accessed January 18, 2018.

6. Weeks WB, Wallace AE, Wang S, Lee A, Kazis LE. Rural-urban disparities in health-related quality of life within disease categories of veterans. J Rural Health. 2006;22(3):204-211.

7. U.S. Government Accountability Office. GAO-18-124. VHA Physician Staffing and Recruitment. https://www.gao.gov/assets/690/687853.pdf. Published October 19, 2017. Accessed January 23, 2018.

8. Veterans Access, Choice, and Accountability Act, section 301 (b): Increase of graduate medical education residency positions, 38 USC § 74 (2014) .

9. Jeff Miller and Richard Blumenthal Veterans Health Care and Benefits Improvement Act of 2016, 38 USC §101 (2016).

10. Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60(10):1323-1328.

11. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80(5):507-512.

12. West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012;308(21):2241-2247.

13. Stimmel B, Haddow S, Smith L. The practice of general internal medicine by subspecialists. J Urban Health. 1998;75(1):184-190.

14. Shea JA, Kleetke PR, Wozniak GD, Polsky D, Escarce JJ. Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association. Med Care. 1999;37(4):333-338.

15. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286(9):1041-1048.

16. Accredited MD programs in the United States. http://lcme.org /directory/accredited-u-s-programs/. Updated December 12, 2017. Accessed January 8, 2018.

17. Osteopathic medical schools. http://www.osteopathic.org/in side-aoa/about/affiliates/Pages/osteopathic-medical-schools.aspx Published 2017. Accessed January 8, 2018.

18. Lincoln A. Second inaugural address. https://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed January 8. 2018.

The VHA is the largest healthcare delivery system in the U.S. It includes 146 medical centers (VAMCs), 1,063 community-based outpatient centers (CBOCs) and various other sites of care. General Omar Bradley, the first VA Secretary, established education as one of VA’s 4 statutory missions in Policy Memorandum No.2.¹ In addition to training physicians to care for active-duty service members and veterans, 38 USC §7302 directs the VA to assist in providing an adequate supply of health personnel. The 4 statutory missions of the VA are inclusive of not only developing, operating, and maintaining a health care system for veterans, but also including contingency support services as part of emergency preparedness, conducting research, and offering a program of education for health professions.

Background

Today, with few exceptions, the VHA does not act as a graduate medical education (GME) sponsoring institution. Through its Office of Academic Affiliations (OAA), the VHA develops partnerships with Liaison Committee for Medical Education (LCME)/American Osteopathic Association (AOA)-approved medical colleges/universities and with institutions that sponsor Accreditation Council for Graduate Medical Education (ACGME)/AOA-accredited residency program-sponsoring institutions. These collaborations include 144 out of 149 allopathic medical schools and all 34 osteopathic medical schools. The VHA provided training to 43,565 medical residents and 24,683 medical students through these partnerships in 2017.² Since funding of the GME positions is not provided through the Centers for Medicare & Medicaid Services (CMS), program sponsors may use these partnerships to expand GME positions beyond their funding (but not ACGME) cap.

The gap between supply and demand of physicians continues to grow nationally.^3,4 This gap is particularly significant in rural and other underserved areas. U.S. Census Bureau data show that about 5 million veterans (24%) live in rural areas.⁵ Compared with the urban veteran population, the rural veteran experiences higher disease prevalence and lower physical and mental quality-of-life scores.⁶ Addressing the problem of physician shortages is a mission-critical priority for the VHA.⁷

With an eye toward enhancing 2 of the 4 statutory missions of the VA and to mitigate the shortage of physicians and improve the access of veterans to VHA medical services, on August 7, 2014, the Veterans Access, Choice, and Accountability Act of 2014 (Public Law [PL] 113-146), known as the Choice Act was enacted.⁸ Title III, §301(b) of the Choice Act requires VHA to increase GME residency positions by:

Establishing new medical residency programs, or ensuring that already established medical residency programs have a sufficient number of residency positions, at any VHA medical facility that is: (a) experiencing a shortage of physicians and (b) located in a community that is designated as a health professional shortage area.

The legislation specifies that priority must be placed on medical occupations that experience the largest staffing shortages throughout the VHA and “programs in primary care, mental health, and any other specialty that the Secretary of the VA determines appropriate.” The Choice Act authorized the VHA to increase the number of GME residency positions by up to 1,500 over a 5-year period. In December 2016, as amended by PL 114–315, Title VI, §617(a), this authorization was extended by another 5 years for a total of 10 years and will run through 2024.⁹

GME Development/Distribution

To distribute these newly created GME positions as mandated by Congress, the OAA is using a system with 3 types of request for proposal (RFP) applications. These include planning, infrastructure, and position grants. This phased approach was taken with the understanding that the development of new training sites requires a properly staffed education office and dedicated faculty time. Planning and infrastructure grants provide start-up funds for smaller VAMCs, allowing them to keep facility resources focused on their clinical mission.

Planning grants (of up to $250,000 over 2 years) primarily were designed for VA facilities with no or low numbers of physician residents at the desired teaching location. Priority was given to facilities in rural and/or underserved areas as well as those developing new affiliations. Applications were reviewed by OAA staff along with peer-selected Designated Education Officers (DEOs) from VA facilities across the nation that were not applying for the grants. Awards were based on the priorities mentioned earlier, with additional credit for programs focused on 2 VHA fundamental services areas—primary care and/or mental health training. Facilities receiving planning grants were mentored by an OAA physician staff member, anticipating a 2- to 3-year time line to request positions and begin GME training.

Infrastructure grants (of up to $520,000 used over 2-3 years) were designed as bridge funds after approval of Veterans Access, Choice, and Accountability Act (VACAA) GME positions. Infrastructure grants are appropriate to sustain a local education office, develop VA faculty, purchase equipment, and make minor modifications to the clinical space in the VAMCs or CBOCs to enhance the learning environment during the period before VA supportive funds from the Veterans Equitable Resource Allocation (VERA) (similar to indirect GME funds from CMS) become available. Applications were managed the same as planning grant submissions.

Position RFPs, unlike planning and infrastructure RFPs, are available to all VAMCs. The primary purpose of the VACAA Position RFP is to fund new positions in primary care and psychiatry. Graduate medical education positions in subspecialty programs also are considered when there is documentation of critical need to improve access to these services. Applications were reviewed by OAA staff along with selected DEOs from VA facilities around the U.S. Award criteria prioritized primary care (family medicine, internal medicine, geriatrics), and mental health (psychiatry and psychiatry subspecialties). Priority also was given to positions in areas with a documented shortage of physicians and areas with high concentrations of veterans.