Funding & Expansion of GME in the Dept. of Veterans Affairs (VA): Veterans Access, Choice, & Accountability Act of 2014 (VACAA)

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1 Funding & Expansion of GME in the Dept. of Veterans Affairs (VA): Veterans Access, Choice, & Accountability Act of 2014 (VACAA) AACOM Conference Call March 17, 2015 Barbara K. Chang, MD, MA, Director, Medical & Dental Education, & Judy Brannen, MD, MBA, Clinical Director, Medical & Dental Education, OAA/VHACO (10A2D)

2 Purpose To provide an overview of GME funding opportunities in the Dept. of Veterans Affairs (VA) To stimulate interest in expansion of VA s GME slots especially in rural and underserved areas 1

3 Outline Background brief history & overview of VA s education mission How VA funds GME GME Enhancement under the Veterans Access, Choice, & Accountability Act (VACAA) of

4 VA Milestones Veterans Administration established as an independent federal agency on July 21, Policy Memorandum No. 2 allowed VA to establish affiliations with medical schools January 30, 1946 Department of Veterans Affairs became cabinet level on March 15, Veteran's Health Care Eligibility Reform Act of 1996 (PL ) Veterans Access, Choice, & Accountability Act of 2014 (VACAA; PL )

5 Veterans Health Administration (VHA) Statutory Missions: 1. Health Care 2. Health Professions Training 3. Research related to health conditions of Veterans 4. Emergency Backup to DoD & part of Nat l Disaster Medical System (HHS, DoD, VA, FEMA)

6 VA s Academic Programs *VA is the largest single provider of health professions education in the US [2 nd after Medicare & Medicaid in funding GME] VHA s educational mission is conducted in collaboration with: o 135 of 141 allopathic & 35 of 40 osteopathic medical school locations. o More than 40 other health professions represented by over 1,800 colleges and universities 128 of 150 VA medical centers, 2 of 6 independent outpt clinics, & 4 other facilities have affiliations for GME and almost all VA facilities have some health professions trainees 5

7 Scope of Physician & Other Health Professions Training in VA [Pre-VACAA] ~41,000 physician residents train in VA annually ~30% of all US total physician residents About 10,250 physician resident positions funded ~9% US positions funded by VA >2,600 ACGME-accredited programs (83 medical specialties & subspecialties; 7 combined programs); the vast majority (>99%) are sponsored by academic affiliates, rather than by VA itself Health Professions Trainees Total Physician Residents 41,223 Medical Students 22,931 Nursing 27,275 Physician Assistants 2,086 All other 27,256 6 Total 120,771

8 How does VA fund GME positions? Annual resident allocation cycle in partnership with affiliates (99%) o Base (permanent) positions applied for in October & approved by early December in time for Match (NRMP) o Filled positions reported post-match (mid-to late March report) final approvals, early May o Flexibility to adjust throughout the year if positions are available 7

9 VA vs. Medicare: Comparison (1) Funding Categories VA Medicare Inpatient rotations Yes Yes Outpatient rotations Scholarly activities, incl. Research Academic coursework (e.g., MPH degree) Didactics & orientation Yes Yes No Yes Subspecialty fellowship years Yes, fully Resident supervision VA Staff physicians Possible under ACA*(called non-hospital ) Yes for DGME; No for IME** No Yes for DGME; if non-hospital, no for IME Yes, half adjusted PRA/DGME DGME intended to cover (but may be inadequate ) *New rule allows payment of DGME & IME, with documentation that the sponsoring institution bears costs of GME **Except when research is directed towards the treatment of a particular patient. 8

10 VA vs. Medicare: Comparison (2) Funding Categories VA Medicare Remedial training Yes No Chief Residents, past core training Non-accredited fellowships Inflation adjustments, stipends Yes No* Yes *Exception: VA-approved Advanced Fellowships (non-accredited) **E.g., reciprocal funding of continuity clinics; educational details possible for training required by 9 ACGME, VETERANS but HEALTH not available ADMINISTRATION at any participating hospital; off-site didactics ***Each hospital counts proportionate share of time, when multiple hospitals incur costs No No Vacation time Yes Yes Quality & safety projects Yes Off-site rotations No, with limited exceptions** Yes, 2-yr (1996 & 97) for primary care Yes No (receiving hospital can claim)***

11 VA vs. Medicare: Comparison (3) FY 2012 VA VA Amt per resident** Medicare CMS Amt per resident*** GME directs* $0.62 B $60,633 $2.6 B $23,259 GME indirects* $0.82 B $79,569 $5.8 B $60,831 Total funding $1.44 B $140,202 $9.4 B $84,090 *Note: these categories are not strictly comparable. VA indirects intended to cover all health professions trainees. **Based upon 10,249 resident POSITIONS ***Based upon a total of 125,034 physician residents (115,293 in ACGME & 9,741 in AOA programs), less VA residents (10,249) and less DoD residents (~3,000).

12 Veterans Access, Choice, & Accountability Act (VACAA) PL : Enacted by Congress & signed by the President on August 7, 2014 Section 301.b o Provision to expand VA GME by up to 1,500 positions over 5 years beginning 1 year after signing o Funding priorities defined (next slide) o Implemented in fall of 2014, with 1-mo. notice o Broad outreach efforts to VA s constituencies & academic community 11

13 Funding Priorities in VACAA Facility Characteristics A shortage of physicians No prior GME Rural locations Areas with a high concentration of veterans HPSAs as defined by HRSA Program Characteristics Primary Care Mental Health New affiliations Other specialties the Secretary deems appropriate 12

14 Application Process: GME Enhancement - VACAA AY for positions starting July 1, 2015: o Via the fall Base Allocation Process through local VA facilities o Rigorous adherence to priorities defined in the legislation Future years: o Via Request for Proposals (RFP) targeting specific areas of interest and encouraging innovation in GME 13

15 Base Allocation Requests for AY Summary of Base Position* Requests, from Oct 2014; approved, Dec 2014 for positions to start July 1, 2015: Base position Requests: AY Requested positions Approved All VACAA GME Non-VACAA GME Totals: * Base Positions are permanent, subject to appropriations.

16 Highlights, Phase 1 allocations: HPSAs, THCs, New Programs & Affiliations Request-specific # # Features* Applications Positions HPSAs** Teaching Health Ctrs (THCs) New programs New affiliations New VA GME sites*** 4 6 *Note: the #applications & #positions are not additive, as several applications met more than one criterion. **Abbreviation: HPSA, Health Professional Shortage Area. Based upon HRSA data. See: ***Atlanta CBOC, Detroit CBOC, Dublin, Grand Junction 15

17 Summary: VACAA GME Position Requests Approved for recruitment AY Filled positions begin July 1, 2015 VACAA GME Initiative Approved Positions % of Total Primary care % Mental health % New and expanding sites % Critical needs* % Rural health 6.7 3% Totals % * Other specialties the Secretary deems appropriate. 16

18 Caveats VACAA positions come with strings attached OAA & VA sites will need to track these positions & funding separately o Cannot be internally reallocated to other positions or purposes Annual reports to Congress on: o Positions awarded o Positions filled/unfilled o If not filled, challenges in filling

19 What VACAA GME is NOT Not a way to fund resident positions at non-va sites Not an opportunity to develop VAsponsored training programs (prohibited by policy) Not a mechanism for funding nonaccredited programs Not focused on GME innovation

20 Infrastructure needs for GME Sufficient workload appropriate to the specialty in which residents are training Qualified faculty to supervise & instruct residents Adequate space to accommodate clinical training equipped with IT resources Capable educational leadership & administrative support staff to manage the GME program, including oversight of: o Resident supervision o Disbursement agreements o Trainee onboarding o Affiliation agreements and relationships o Resident satisfaction and trainee-related issues 19

21 Future GME Enhancement: VACAA RFPs Start-up support for GME naïve sites (FY 2015) o Infrastructure support to ensure a quality educational experience & adequate/appropriate resident supervision o Planning grants to incentivize future GME relationships Timeline next cycle of VACAA GME Enhancement: o RFPs planned for late spring 2015 o Review summer 2015 o Awards finalized Sept/Oct 2015 o Positions start July 1, 2016 (for AY ) o Next 4 years: add between positions per year.

22 Conclusions VA provides opportunities for funding and expansion of GME positions especially in non-traditional clinical teaching sites with new affiliations under new, VACAA legislation Outreach to THCs and other programs in rural & underserved areas is encouraged Watch for VACAA GME RFP to be released in late spring

23 Questions??? Barbara K. Chang, MD, MA Director, Medical & Dental Education, OAA (502) , Judy Brannen, MD, MBA Clinical Director, Medical & Dental Education, OAA (804) , For Program Announcements & RFPs, see: 22

24 For reference only: Veterans Access, Choice & Accountability Act of 2014, Sec. 301 [PL ] TITLE III HEALTH CARE STAFFING, RECRUITMENT, AND TRAINING MATTERS SEC TREATMENT OF STAFFING SHORTAGE AND BIENNIAL REPORT ON STAFFING OF MEDICAL FACILITIES OF THE DEPARTMENT OF VETERANS AFFAIRS. (b) INCREASE OF GRADUATE MEDICAL EDUCATION RESIDENCY POSITIONS. (1) IN GENERAL. Section 7302 of title 38, United States Code, is amended by adding at the end the following new subsection: (e)(1) In carrying out this section, the Secretary shall establish medical residency programs, or ensure that already established medical residency programs have a sufficient number of residency positions, at any medical facility of the Department that the Secretary determines (A) is experiencing a shortage of physicians; and (B) is located in a community that is designated as a health professional shortage area (as defined in section 332 of the Public Health Service Act (42 U.S.C. 254e)). (2) In carrying out paragraph (1), the Secretary shall (A) allocate the residency positions under such paragraph among occupations included in the most current determination published in the Federal Register pursuant to section 7412(a) of this title; and (B) give priority to residency positions and programs in primary care, mental health, and any other specialty the Secretary determines appropriate.. (2) FIVE-YEAR INCREASE. (A) IN GENERAL. In carrying out section 7302(e) of title 38, United States Code, as added by paragraph (1), during the 5-year period beginning on the day that is 1 year after the date of the enactment of this Act, the Secretary of Veterans Affairs shall increase the number of graduate medical education residency positions at medical facilities of the Department by up to 1,500 positions. (B) PRIORITY. In increasing the number of graduate medical education residency positions at medical facilities of the Department under subparagraph (A), the Secretary shall give priority to medical facilities that (i) as of the date of the enactment of this Act, do not have a medical residency program; and (ii) are located in a community that has a high concentration of veterans. 23

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