Veterans Choice Act: Update on the VA GME Expansion
Kathleen Klink, MD, FAAFPMedical and Dental Education
&Edward Bope, MD, FAAFPGME Affiliations Officer
Office of Academic AffiliationsVeterans Health Administration
VETERANS HEALTH ADMINISTRATION
Graduate Medical Education –Current Scope
• Over40,000physicianresidentsrotatethrough10,200FTEEsalarylines(3to4residentsperFTEE)– 1/3ofallUSallopathicresidents
• Over$650milliondollarsinfunding• Mostcomplexity1a,1band1cfacilitieshaveGMEprograms;fewcomplexity2facilities
• GMEhasalwaysbeenseenasa“bigfacility”endeavorbutthingsarechangingrapidly
VETERANS HEALTH ADMINISTRATION
Veterans Access, Choice, & Accountability Act (VACAA)
• PL113-146:EnactedbyCongress&signedbythePresidentonAugust7,2014– Section301(b)o ProvisiontoexpandVAGMEby“upto1,500positions”over5yearsbeginning1yearaftersigning
o Fundingprioritiesdefined(nextslide)o AnnualCongressionalreportingrequirementsregardingthefilledVACAApositionsandtheirVAlocations
VETERANS HEALTH ADMINISTRATION
Funding Priorities in VACAA
FacilityCharacteristics• Ashortageofphysicians• NopriorGME• Areaswitha“highconcentrationofVeterans”
• HealthProfessionalShortageAreas(HPSAs)asdefinedbyHRSA
ProgramCharacteristics• PrimaryCare• MentalHealth• Otherspecialties“theSecretarydeemsappropriate”(interpretedasthosespecialtieshavingexcessivewaittimesforcare)
VETERANS HEALTH ADMINISTRATION
Legislative Priorities Require Different GME Emphasis
• VACAAGMEauthoritycanbeusedasleveragetoassistwithUSphysicianmaldistributionandsub-specialtypredominance
• Workingwithcommunitypartners,VAGMEexpansioncangreatlyimpactsmallercommunitiesandsmallerVAMCsby– Increasingthelocalworkforcepipeline– Over60%ofGMEparticipantsstaywithin100milesoftheirtraininglocationpost-residency
VETERANS HEALTH ADMINISTRATION
Legislative Priorities Require Different GME Outreach
• VACAAGMEPrioritiesrequire– OutreachtoOsteopathicMedicalSchoolsandOPTIs– OutreachtoFamilyMedicineCommunityBasedPrograms– OutreachtopartnershipswithFederallyQualifiedHealthCentersandTeachingHealthCenters
– OutreachtoRuralTrackTrainingPrograms– PartnershipswithComplexityLevel2and3VAMCs– PartnershipsfortraininginCommunityBasedOutpatientClinicsandHealthCareCenterswithallsizeVAMCS
VETERANS HEALTH ADMINISTRATION
YEAR 1: VA GME Expansion Requests Approved for AY 2015-16
Focus ApprovedPositions
%ofTotal
PrimaryCare 102.4 50%
MentalHealth 57.8 28%
CriticalNeeds 44 22%
Total 204.2 100%
VETERANS HEALTH ADMINISTRATION
YEAR 2: VA GME Expansion Requests Approved for AY 2016-17
VETERANS HEALTH ADMINISTRATION
Expanding Graduate Medical Education
• VAcannotexpandGMEbyitself- wedonotcreateourownresidencyprograms
• Communitypartnerswillbevitaltoassistwithidentifyingexpansionopportunitiesthatmeetthelegislativepriorities
• SmallerVAMCsmayneedassistanceto“getintotheGMEgame”
• OAAhasbudgetedforextensivefinancialassistancetostartupfledglingGMEprograms
VETERANS HEALTH ADMINISTRATION
Types of Assistance
ü PlanningGrantsü VACAADirectResidentStipendandBenefitPaymentsü InfrastructureGrants– tooffsetcostsofprotectedtimeforfaculty,recruitmentofanexperiencedDEO,educationofficestaffing,minorspacemodifications,facultydevelopment
ü ExtensiveOAAconsultationü SiteVisitsü PartnerMatchingServices
VETERANS HEALTH ADMINISTRATION
GME – PROs and CONs
PROs• Bringsanewworkforcepipeline into
yourfacilityandcommunity –improvesrecruitment
• Facultyresponsibilities fosterrecruitment ofhigherqualitymedicalstaffmemberswhowanttoparticipate ineducationorresearchprograms
• AllowsexpansionofscopeofhealthcareprogramsforVeteransandaccess forVeterans
• Academiccultureenhances evidence-basedpractice, improvingqualityofcare
CONs
• Currentstaffmembersmayneedfacultydevelopment tolearnsupervision andteachingskills
• NewstaffmayneedtoberecruitedtodoGMEwell
• Residents mayslowproductivityatearlystages,butimprovestaffproductivityastheylearn
• Needprotectedtime forsupervisingandteachingfaculty
• NeedaSiteDirector,DEO,andstaffassistance torunGME– costs$$
VETERANS HEALTH ADMINISTRATION
Successful Round One Case Studies
ü DURHAM VAMC & DUKE Dept Fam Med, ACGME Accredited
ü One FTE/year over 3 years for total expansion of 3 FTEs
ü Residents participate in Academic PACT continuity clinic at the VAMC
ü Documentation of PC need:
ü Increased need: encounters, unique patients, total bed days/year
ü Wait time for new PC patients > 30 d
ü High percentage of patients cared for at VAMC site (not in geographic HPSA), who live in HPSAs
VETERANS HEALTH ADMINISTRATION
Successful Round One Case Studies
ü Memphis VAMC and Univ of TN College of Medicine
ü ACGME Accredited
ü Two positions in Round One
ü VA COS wants FM due to difficulty recruiting FM to PC and VAMC’s 9 CBOCs (all are in HPSAs)
ü Psych and Derm rotations to alleviate long wait lists
ü Supervision by VA providers
VETERANS HEALTH ADMINISTRATION
Successful Round One Case Studies
ü Detroit VAMC and Detroit Wayne County Health Authority
ü AOA Accredited
ü Geriatrics rotation at Community Living Center (CLC) with exposure to hospice and palliative outpatient and consultative care
ü Supervision by VA geriatricians
ü County is MUA with anticipated PC shortage
VETERANS HEALTH ADMINISTRATION
Successful Round Two Case Studies
ü Bedford VAMC/ Boston Medical Center – Family Medicine
ü 2 positions first year, then ramp up by 2 additional/year x 3 years
ü Access not as much of a problem in this VISN as recruitment/retention
ü Primary care residents exposed to intellectual challenges with VA patient populations
VETERANS HEALTH ADMINISTRATION
Successful Round Two Case Studies
ü Columbia VAMC and Greenville Health System, U of SC
ü New Affiliate is a new med school located near the CBOC—both HPSA & rural setting
ü Currently FM program has no experience with Veterans or with PACT model
ü Residents will learn benefits of integrated care model, unique female veterans issues and benefit from a mini-clinic in musculo-skeletal care
VETERANS HEALTH ADMINISTRATION
Successful Round Two Case Studies
ü Loma Linda VAMC & Inland Empire Consortium for Healthcare Education
ü Located in a primary care HPSA, rapidly growing population, 50% p.c. shortage
ü VA primary care wait times >30 days due to 5% increase in demand/year and no staff increase over 4 years
ü High poverty, ethnic & minority diversity, low high school education level
VETERANS HEALTH ADMINISTRATION
Primary Care and Mental Health Residency Infrastructure Grant Support Available for VACAA Position Recipients—January 2016
Medical Support and Compliance: Funds support overhead costs associated with maintaining GME programs, as exemplified in the OAA Handbook 1400.10.
Medical Services: Funds support salaries of VA staff who instruct or supervise residents and trainees. They may also be used to supplement staff salaries within an education office.
Facility funds: Support costs of minor construction projects, or augment major construction projects that allow necessary space expansion to accommodate increased VACAA GME positions training capacity.
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VETERANS HEALTH ADMINISTRATION
Funding for 2016 and Projected Future Fiscal Years
• MedicalSupportandCompliance– 3years: $1,277,688– 2016: $567,742
• MedicalServices– 3years: $7,117,811– 2016: $1,396,955
• FacilityFunds– 3years: $1,222,389– 2016: $520,651
• Total2016: $2,485,336• Projected3yeartotal: $9,496,161
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VETERANS HEALTH ADMINISTRATION
Eligible VA Sites for Planning Grants Released February 19, 2016
Find the VA Closest to Your Residency Training Program
AlexandriaVAMC ErieVAMC PoplarBluff,MOVAMCAltoona,PAVAMC FortWayneVAMC PrescottVAMCAnchorageVAMC Ft.Harrison,MT RoseburgVAMCAshevilleVAMC HarlingenVAMC Sheridan,WYVAMCBath,NYVAMC IronMountain,MI SpokaneVAMCBedfordVAMC LyonsVAMC St.Cloud,MNVAMC
BlackHillsHCS,SD Manchester,NHVAMC Tomah,WIVAMCButler,PAVAMC MarionVAMC(IL) TopekaVAMCCheyenneVAMC MartinsburgVAMC TuscaloosaVAMCClarksburgVAMC MontgomeryVAMC WallaWalla VAMC
Coatesville,PAVAMC MuskogeeVAMC WhiteCity,ORVAMCDanvilleVAMC NewingtonVAMC
DesMoinesVAMC NorthamptonVAMC
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VETERANS HEALTH ADMINISTRATION
Into the Weeds for RTT!
• TwoModels forExpanding RTT
• Scenario#1:• OnenewVA-VACAAFTEeachyearfortwoyears=TWOFTEs
– 2FTE=24VAmonths=6residenteachdoing4monthsattheVAannually
• Scenario#2• One-halfnewVA-VACAA FTEeachyearfortwoyears=OneFTE• OneFTE=12VAmonths:sixresidents eachdo2monthsofVAEACHyear
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VETERANS HEALTH ADMINISTRATION
Models for Types of Rotations• Longitudinal
– Continuity clinicalexperience attheVA– Nursinghomeassigned patients andfollowups– Anyspecialty rotationswithlongitudinal format,e.g.psychiatry,rehab,homebased
care
• Rotations– Dermatology– Surgery(in-pt andout-pt)– Urology– Radiology– UrgentorEmergencyCare– ICU:Med,cardiac– Neurology– Psychiatry– Oncology– CommunityMedicine
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VETERANS HEALTH ADMINISTRATION
Concept of Shared Faculty Between VA and Family Medicine Training Programs
• Focusclinicalexperiences onfamilymedicineledclinicalcare
• Familymedicine facultyhaveappointments atVAand atFamilyMedicinesponsoringprogramaffiliate, suchastheteachinghospital,medicalschool
• Topicalareaswhere familymedicinecanprovideclinicalteachingandVAneedsclinicalskillsfamilymedicinecanprovide thatwillimproveaccess forvets:
– Women’shealth– Biopsiesgeneratedthroughderm telehealth consultationservices– Geriatrics– Palliativecare– Other,additionalasidentifiedthroughdiscussionwithlocalVAfacilityleadership
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VETERANS HEALTH ADMINISTRATION
Questions? / Contact Info
Contact: [email protected]
Kathleen Klink, MD, FAAFP
Director of Medical & Dental Education, Office of Academic Affiliations
Edward Bope, MD, FAAFP
GME Affiliations Officer, Office of Academic Affiliations
VETERANS HEALTH ADMINISTRATION
For reference only: Veterans Access, Choice & Accountability Act of 2014,
Sec. 301 [PL 113-146]TITLEIII—HEALTHCARESTAFFING,RECRUITMENT,ANDTRAININGMATTERSSEC.301.TREATMENTOFSTAFFINGSHORTAGEANDBIENNIALREPORTONSTAFFINGOFMEDICALFACILITIESOFTHEDEPARTMENTOFVETERANSAFFAIRS.(b)INCREASEOFGRADUATEMEDICALEDUCATIONRESIDENCYPOSITIONS.—(1)INGENERAL.—Section7302oftitle38,UnitedStatesCode,isamendedbyaddingattheendthefollowingnewsubsection:‘‘(e)(1)Incarryingoutthissection,theSecretaryshallestablishmedicalresidencyprograms,orensurethatalreadyestablishedmedicalresidencyprogramshaveasufficientnumberofresidencypositions,atanymedicalfacilityoftheDepartmentthattheSecretarydetermines—‘‘(A)isexperiencingashortageofphysicians;and‘‘(B)islocatedinacommunitythatisdesignatedasahealthprofessionalshortagearea(asdefinedinsection332ofthePublicHealthServiceAct(42U.S.C.254e)).‘‘(2)Incarryingoutparagraph(1),theSecretaryshall—‘‘(A)allocatetheresidencypositionsundersuchparagraphamongoccupationsincludedinthemostcurrentdeterminationpublishedintheFederalRegisterpursuanttosection7412(a)ofthistitle;and‘‘(B)giveprioritytoresidencypositionsandprogramsinprimarycare,mentalhealth,andanyotherspecialtytheSecretarydeterminesappropriate.’’.(2)FIVE-YEARINCREASE.—(A)INGENERAL.—Incarryingoutsection7302(e)oftitle38,UnitedStatesCode,asaddedbyparagraph(1),duringthe5-yearperiodbeginningonthedaythatis1yearafterthedateoftheenactmentofthisAct,theSecretaryofVeteransAffairsshallincreasethenumberofgraduatemedicaleducationresidencypositionsatmedicalfacilitiesoftheDepartmentbyupto1,500positions.(B)PRIORITY.—InincreasingthenumberofgraduatemedicaleducationresidencypositionsatmedicalfacilitiesoftheDepartment undersubparagraph(A),theSecretaryshallgiveprioritytomedicalfacilitiesthat—(i)asofthedateoftheenactmentofthisAct,donothaveamedicalresidencyprogram;and(ii)arelocatedinacommunitythathasahighconcentrationofveterans.
