Joanna Sells is a US Department of Veterans Affairs (VA) and University of California, San Francisco (UCSF) Quality Scholar Psychology Fellow. John McQuaid is Associate Chief of Staff for Mental Health, both at the San Francisco VA Health Care System and Vice Chair, Department of Psychiatry Weill Institute of Neuroscience, UCSF. Correspondence: Joanna Sells (joanna.sells@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
VA has been training clinicians and scholars since 1946, when VA academic affiliations were established by Memorandum Number 2.15,16 Today, the VA is the largest educator of HCPs in the United States.17 In 2015, an estimated $10.3 to $12.5 billion was spent on mandatory Medicare graduate medical education (GME).18 In 2017, the VA spent $1.78 billion of discretionary funding on GME to fund 11,000 full-time equivalent (FTE) slots, leading to > 43,000 physician residents (> 30% of all physician residents) spending part of their training in a VHA facility.18,19
This training mission has multiple benefits. It provides the VA with access to new HCPs who have the necessary training in veteran-specific needs, while supporting the national need for HCPs. In 2018, 120,890 clinical trainees received some or all of their training in the VA system.20 Of the 152 US medical schools that are accredited by the Liaison Committee on Medical Education, 95% collaborate with the VA for training while 100% of the 34 doctor of osteopathic medicine programs have VA training collaborations.20 The VA currently has an additional 18 partnerships with nursing schools.21 Further, 1,800 college and universities, including Hispanic-serving institutions and historically black colleges and universities, have VHA affiliations that provide training for more than 40 clinical health profession education programs.17
This training model has been successful in supporting VA staffing, as health care providers who trained in the VA are more likely to work in the VA.22 Among current VA employees, > 80% of optometrists, > 70% of podiatrists and psychologists, and > 60% of physicians received some part of their training in the VA system.23 In combination with recent increased funding for staffing, the ability of the VA to directly hire trainees in identified professions, and the expansion of loan forgiveness to high-demand specialties (eg, psychiatry), the training partnership between the VA and affiliates has been critical in maintaining the needed VA workforce.22,24,25
The VA Office of Academic Affiliations is responsible for all graduate medical and dental education administration in the VA system, which makes up 85% of its total budget. For each trainee, the VA provides approximately $60,000 toward their stipend in exchange for training and patient care time at a VHA hospital (Kenneth R. Jones, PhD, email communication, August 27, 2018).
California Health Care Education
The UC public university system, founded in 1869, currently has 10 campuses with a combined student body of > 280,000 students, along with 227,000 faculty and staff members.26 For every research dollar provided by California, the UC secures $7 in federal and private funding.26 The UC has 6 medical centers (Davis, Irvine, Los Angeles, Riverside, San Diego, and San Francisco); each is affiliated with at least 1 local VAMC.27,28
California trains a substantial share of health care trainees. In 2016, there were 10,429 physician residents in training in California.29 In 2017/2018, the San Francisco VAMC trained 1,178 medical students/residents, 57 pharmacy students, 25 nurse practitioner students, 19 optometry interns/students/residents, 11 dental students/residents, and 3 physical therapy students.20 In total, 6,223 UC health professions students were trained in VHA facilities during the 2017/2018 training year (Table 4).20 As of 2016, there were 105,907 physicians in California, and of those, 57% completed their GME in California.29 In California in 2015, 74 GME-sponsoring institutions graduated 3,568 residents and fellows, an increase of 10% since 1997.30 Of these sponsoring institutions, 6 of the top 8 programs were UC schools that graduated 48.4% (1,727) of all California residents and fellows in 2015.30
Despite these resources, California faces a major shortage of HCPs, particularly in primary, behavioral health, and older adult care.3 Today, 7 million Californians live in counties with a federally designated shortage of primary, dental, and mental health care providers.3 Most of these Californians are Latino, African American, or Native American, and they live in fast-growing rural and urban regions, including Los Angeles; the San Joaquin Valley; and the Inland Empire (San Bernardino and Riverside Counties).3 Current recommendations to meet increasing demands as California’s population increases, grows older, and faces increased health care demands include expanding residency programs to yield 1,872 additional primary care physicians and 2,202 additional psychiatrists by 2030.3 To meet this shortage and prepare for future health care demands, health care education is paramount; in California, VA and UC affiliations are central to addressing these needs.
The VA plays a particularly important role in supporting GME, which is essential to meeting both VA and California’s unmet HCP needs, as GME determines the number of medical practitioners available per specialty.30 The VA was the second largest GME fund provider in California at $90,662,608 (Medicare provided $552,235,626) and the California government provided a small portion of GME funding.30 VA education funding is a direct result of the VA provision of clinical care in one of the most innovative and modern health care systems in the world.
These VA training opportunities benefit the UC system and California by helping train integrated care practitioners to meet the increasing demand. Integrated care—the coordination of mental health care, substance use disorder treatment, and primary care services—is designed to improve health outcomes by helping people with multiple and complex health care needs access care.31,32
As the largest integrated health care system in the country, the VA brings important clinical, research, and educational opportunities to academic affiliates. A systematic review examining cost and quality outcomes in integrated care systems found improved quality of care compared with nonintegrated care systems; thus, many US government agencies and the World Health Organization are establishing integrated care systems as a standard and universal approach.31,33,34 While cost savings as a result of integrated care are unclear, most studies in this review reported a decrease in utilization of services.33 The presumption of more efficient and higher quality care is also predicated on features such as system-wide accessibility of comprehensive medical records that provide more information to HCPs, promote collaboration, and measure and reward performance, all of which are possible using the VA electronic health record (EHR) system.35,36 The VA offers an excellent opportunity for training in integrated care as this model is required of all VAMCs and community-based outpatient clinics (CBOCs).37
Providing integrated care to the citizens of California is among the 10 priorities of the California Future Health Workforce Commission (a group of California health care leaders cochaired by the UC system president) for immediate action and guides their recommendations on developing and expanding the health care workforce; therefore, training in an integrated health care system is especially important for California HCPs.3 Nearly three-quarters of California’s population aged ≥ 65 years has a chronic health condition that could benefit from integrated care; however, the current supply of HCPs is insufficient to meet the growing demand for geriatric care.38,39
The VA has a robust training program to produce scholars and practitioners who specialize in geriatric care. This includes the Geriatric Scholars Program, which has the goal of integrating geriatrics into primary care through professional development. The Geriatric Scholars Program is a component of the VA Geriatric Research Education and Clinical Centers at urban VAMCs to help provide education and clinical resource connections with rural CBOCs where geriatrics expertise is lacking.
The California Future Health Workforce Commission is highlighting the need to prioritize workforce development in primary care, mental health care, and care for the aging.3 These priorities are shared as foundational services within the VHA.40 The alignment of these priorities creates an excellent rationale for increasing training and education of the UC health care workforce in the California VA system through academic affiliations.
