The effort to recruit and train physicians to tend to the specific and often very locally focused needs of VA patients is slow-going despite its fast-track implementation, according to the Veterans Affairs Department.
The Veterans Access, Choice, and Accountability Act of 2014 (PDF) contained an ambitious provision to create 1,500 new VA-affiliated graduate medical education positions in five years. The legislation aimed to put resident physicians in areas of need with the hopes that they would remain there to practice.
A request for proposals was issued last fall for new residency positions that were to start July 1, 2015. Those interested had only a few weeks to apply. More than 200 proposals were accepted, 75% of them in mental health or primary-care specialties, said Dr. Karen Sanders, the VA's deputy chief academic affiliations officer.
Matthew Shick, senior legislative analyst with the Association of American Colleges, called that a “fantastic feat.”
“Typically, those RFPs are open for months,” he said.
Sanders agreed, saying the initial RFP for the first round of residency positions was only “on the street for four weeks, but we got an amazing, robust response.”
To some extent, however, it was too much, too soon, and only 162.9 of those new positions were filled by residents July 1.
Sanders said her office has reached out to the facilities that didn't fill their allotted positions. She was told that all were willing, but they had problems doing so in the time allowed.
The first RFP stated that facilities would receive $87,000 a year per resident allocated as “indirect education support.” That figure was lowered to $83,000 in the second RFP (PDF), which covers 325 new positions scheduled to start July 1, 2016.
That initial RFP (PDF) also noted that “Programs that incorporate teaching of principles of patient-aligned care teams and integration of residents into PACT models of care delivery will be given priority.”
Also, all new GME positions needed to be sponsored by an academic affiliate. The new slots could not be sponsored by a VA facility and expanding existing VA-sponsored residencies was not considered.
Under optimal conditions, Sanders said it can take more than seven years for a residency program starting from scratch to be fully operational. So she predicted the next rounds of new program development will require a major relationship-building and recruitment effort by the VA.
Three elements are required for a new residency program, Sanders said. These include a willingness to participate in GME, an experienced educational leader who will be given time to train and supervise residents, and adequate clerical support.
“Ultimately, it's about veterans' access to care and to improve the workforce pipeline for both the VA and the communities they are located in,” she explained.
Studies have shown that new physicians tend to begin their practices in the areas or facilities they trained. The VA is no exception. It reports that roughly 70% of current VA-employed optometrists, physicians and psychologists participated in VA training programs prior to employment.
Shick said that most residents usually train only three to four months a year at VA facilities and then spend the rest at an academic medical center or some other teaching healthcare institution.
He said most AMCs can absorb these new positions, but only in the short term or in small numbers and that more Medicare funding for GME will eventually be needed.
The number of Medicare-supported residency positions has stayed roughly the same since 1997. But Medicare is still the largest source of GME funding. In 2012, it spent $9.7 billion on GME, while Medicaid contributed $3.9 billion, the Veterans Affairs Department spent $1.4 billion, and HHS' Health Resources and Services Administration provided about $500 million.
“Even if the VA got all 1,500 positions off the ground, they would not be sustainable long term without a corresponding Medicare increase,” Shick said.
Sanders agreed explaining that the “VA can't be the only funder” for these new positions and that the cap on Medicare GME spending could inhibit the Veterans Choice GME program from reaching its potential.
She acknowledged, however, that opponents of increasing Medicare spending on GME have accused the AAMC of using the VA-access issue as a political football to advance its cause of increasing the number of residency positions.
“There's a lot of spin everywhere, but this is a real barrier to us,” Sanders said.
The Senate Committee on Veterans' Affairs will be holding an Aug. 21 hearing in Gainesville, Ga., on the ongoing implementation of the Veterans Choice Act. VA Secretary Robert McDonald is scheduled to attend along with Dr. James Tuchschmidt, the VA's acting principal deputy under secretary for health.