The Veterans Health Administration and
Medical Education: A Fact Sheet
Elayne J. Heisler
Analyst in Health Services
Erin Bagalman
Analyst in Health Policy
June 6, 2014
Congressional Research Service
7-5700
www.crs.gov
R43587
The Veterans Health Administration and Medical Education: A Fact Sheet
Contents
Background ...................................................................................................................................... 1
The VA’s Involvement in Medical Training ..................................................................................... 1
Academic Affiliations ................................................................................................................ 2
Academic Appointments ........................................................................................................... 2
VA Funding of Physician Training................................................................................................... 3
Figures
Figure 1. VA Facilities and Medical Schools, with and without Affiliations ................................... 3
Figure 2. VA Spending on Health Care Professional Education and Training (FY2010 –
FY2016 Advance Appropriation Request).................................................................................... 4
Tables
Table 1. VA Medical Training at the Trainee Level (2013).............................................................. 1
Contacts
Author Contact Information............................................................................................................. 5
Congressional Research Service
The Veterans Health Administration and Medical Education: A Fact Sheet
Background
In the wake of World War II, an influx of veterans requiring medical care threatened to
overwhelm the capacity of the Department of Veterans Affairs (VA) to provide such care. In 1946,
the VA began entering into affiliations with medical schools as one strategy to increase capacity
both in the short term and in the long term.1 In the short term, some trainees—in particular, those
in the later years of training—may provide direct care to patients, thereby increasing provider
capacity and patient access. In the long term, training physicians at the VA creates a pipeline for
recruiting physicians as VA employees.2 Current concerns about the VA’s capacity to provide
access to care3 have returned attention to the role of medical training at the VA.4
The VA’s Involvement in Medical Training
The VA is the largest provider of medical training in the United States and is involved in training
Medical Education: A Fact Sheet
January 19, 2016
(R43587)
Background
Training health care professionals—including physicians—is part of the VA's statutory mission.1 It does so to provide an adequate supply of health professionals overall and for the VA's health system. This mission began in 1946, when the VA began entering into affiliations with medical schools as one strategy to increase capacity.2 Some trainees—in particular, those in the later years of training—may provide direct care to patients, thereby increasing provider capacity and patient access. In the long term, training physicians at the VA creates a pipeline for recruiting physicians as VA employees.3 In 2014, the Veterans Access, Choice, and Accountability Act of 2014 VACAA, P.L. 113-46, as amended) initiated an expansion of the VA's medical training by requiring the VA to increase the number of graduate medical education positions at VA medical facilities by 1,500 positions over a five-year period beginning July 1 of 2015, through 2019.4
The VA's Involvement in Medical Training
The VA is the largest provider of medical training in the United States and is involved in training at all levels: medical students, medical residents, and medical fellows (see Table 1
).5
).5
Table 1. VA Medical Training at the Trainee Level (
2013)
Number in Training (2013)
Trainee Type
Description
VA
U.S. Total
(including VA)
Medical
Students
The VA serves as a site for clinical rotations during medical
school; this is also called undergraduate medical education.
21,540
105,213
Medical
Residents
Through affiliations with hospitals and academic medical
centers, the VA serves as a training site for medical residents;
this is also called graduate medical education (GME).
40,420
94,990
Fellows
Through affiliations with hospitals and academic medical
centers, the VA serves as a training site for fellows
(individuals who have completed residency training and are
pursuing additional training in order to subspecialize.)
253
20,121
Sources: VA data from U.S. Department of Veterans Affairs. Office of Academic Affiliations, "Medical and
Dental Education Program," http://www.va.gov/oaa/specialfellows/default.asp?p=1, website accessed June 5, 2014.
1
See U.S. Department of Veterans Affairs, Policy Memorandum No. 2, Subject: Policy in Association of Veteran's
Hospitals with Medical Schools, Washington, DC, January 30, 1946, http://www.va.gov/oaa/Archive/
PolicyMemo2.pdf.
2
The VA reports that nearly 70% of VA physicians had trained at the VA prior to their employment. U.S. Department
of Veterans Affairs (VA). Office of Academic Affiliations, "Mission of the Office of Academic Affiliations,"
2014-2015)
|
Trainee Type
|
Description
|
Number in Training (2014-2015)
|
VA
|
U.S. Total (including VA)
Medical Students
|
The VA serves as a site for clinical rotations during medical school; this is also called undergraduate medical education.a
Medical Residents
|
Through affiliations with hospitals and academic medical centers, the VA serves as a training site for medical residents; this is also called graduate medical education (GME).
|
Fellows
|
Through affiliations with hospitals and academic medical centers, the VA serves as a training site for fellows (individuals who have completed residency training and are pursuing additional training in order to subspecialize.)
|
Sources: VA data from U.S. Department of Veterans Affairs. Office of Academic Affiliations, "2014 Statistics: Health Professions Trainees," http://www.va.gov/
oaa/docs/OAA_Statistics.pdf. Medical school enrollment data from the Association of American Medical Colleges, "Table B-1.2: Total Enrollment at U.S. Medical School and Sex," and American Association of Colleges of Osteopathic Medicine, "Preliminary Enrollment Report Fall 2015." Medical Resident and Fellow data from: Sarah E. Brotherton and Sylvie I. Etzel, "Graduate Medical Education, 2014-2015," oaa/specialfellows/default.asp?p=1, website accessed June 5, 2014.
3
See, for example, CRS Report IN10063, Wait Times for Veterans Health Not New, by Sidath Viranga Panangala; and
Veterans Health Administration, "Interim Report: Review of Patient Wait Times, Scheduling Practices, and Alleged
Patient Deaths at the Phoenix Health Care System," May 28, 2014, http://www.va.gov/oig/pubs/VAOIG-14-02603178.pdf, website accessed June 2, 2014.
4
The training of health care professionals is also one of the VA’s statutory missions; see 38 U.S.C. §7302.
5
U.S. Congress, House Committee on Veterans' Affairs, Subcommittee on Health, Healthcare Professionals—
Recruitment and Retention, 110th Cong., 1st sess., October 18, 2007 (Washington: GPO, 2008), p. 40.
Congressional Research Service
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The Veterans Health Administration and Medical Education: A Fact Sheet
Medical school enrollment data from the Association of American Medical Colleges, “Table 26: Total Enrollment
at U.S. Medical School and Sex,” https://www.aamc.org/data/facts/enrollmentgraduate/158808/total-enrollmentby-medical-school-by-sex.html, website accessed June 5, 2014; and American Association of Colleges of
Osteopathic Medicine, “ Trends in Osteopathic Medical School Applicants, Enrollment, and Graduates,”
http://www.aacom.org/data/applicantsmatriculants/Pages/default.aspx, website accessed June 5, 2014. Medical
Resident and Fellow data from: Sarah E. Brotherton and Sylvie I. Etzel, "Graduate Medical Education, 2012-2013,"
Journal of the American Medical Association, vol.
310314, no.
2122 (December
4, 2013), pp. 2328-2346.
Notes: Total reflects allopathic and osteopathic enrollment8, 2015), pp. 2436-2454.
Notes: Total reflects allopathic and osteopathic enrollment.
a.
In general, medical education consists of four years of college education leading to a bachelor's degree followed by four years of medical school (also known as undergraduate medical education). Medical students during their first two years are
generally receiving classroom instruction and not clinical training; therefore, they would not be eligible to rotate
to any type of a facility for clinical instruction.
Academic Affiliations
The VA’
Academic Affiliations
The VA's physician training programs are conducted primarily through its affiliations with
medical schools and, in some instances, with teaching hospitals. In general, the purpose of these
affiliation agreements is to enhance patient care and education, but some may also include
medical research. Under these affiliation agreements, the VA and the relevant educational
institution share responsibility for the academic program. The affiliation agreement promotes
common standards for patient care, medical student and resident education, research, and staff
appointments.
6 Generally, the VA is not the primary sponsor of medical education.7 Specifically,
6 During the 2014-2015 academic year, 134 VA medical facilities were affiliated with 135 of 141 allopathic medical schools and 36 of 40 osteopathic medical schools.7 Under affiliation agreements, VA clinicians may, at the discretion of the academic institution, be granted academic appointments to medical school faculty. Approximately 70% of VA staff clinicians have a faculty appointment at an affiliated school of medicine.8 VA staff clinicians may be jointly employed by the VA and the affiliated medical center, may volunteer their time as faculty, or the VA may contract with the academic affiliate for faculty.
Generally, the VA is not the primary sponsor of medical education.9 Specifically, the VA does not operate its own medical schools, but medical students from affiliated institutions
may do a clinical rotation at affiliated VA facilities. Similarly, the VA does not typically operate
its own residency programs. Instead, residents apply to the medical school or teaching hospital
that is the primary sponsor of the residency program and then spend a portion of their residency
training at the VA. The exception to this model is fellowship level training, where the VA directly
operates fellowship training programs in subspecialties that are of high importance to the VA.8
The majority of VA facilities and the majority of U.S. medical schools (both allopathic and
osteopathic)9 have affiliation agreements with each other to train physicians (see Figure 1).
Academic Appointments
Under affiliation agreements, VA clinicians may be granted academic appointments to medical
school faculty at the discretion of the academic institution based on the clinician’s credentials.
Currently, approximately 70% of VA staff clinicians have a faculty appointment at an affiliated
school of medicine.10 VA staff clinicians may be jointly employed by the VA and the affiliated
6
Drawn from a sample copy of VA Form 10-0094a, “Medical Education Affiliation Agreement Between Department
of Veterans Affairs (VA), and A School Of Medicine and its Affiliated Participating Institutions.”
7
The VA reports that 99% of its graduate medical education training programs are sponsored by an affiliate. See U.S.
Department of Veterans Affairs, Office of Academic Affiliations, "Medical and Dental Education Program,"
http://www.va.gov/oaa/specialfellows/default.asp?p=1, website accessed June 5, 2014.
8
For more information, see U.S. Department of Veterans Affairs, Office of Academic Affiliations, "Advanced
Fellowships and Professional Development," press release, http://www.va.gov/oaa/specialfellows/default.asp?p=1,
website accessed June 5, 2014.
9
Allopathic medical schools grant a Doctor of Medicine degree (M.D.); osteopathic medical schools grant a Doctor of
Osteopathic Medicine degree (D.O.).
10
Veterans Health Administration, Procurement & Logistics Office, The Academic Affiliate Guide to Health Care
Resources Contracting with the Department of Veteran's Affairs, 2014.
Congressional Research Service
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The Veterans Health Administration and Medical Education: A Fact Sheet
medical center, may volunteer their time as faculty, or the VA may contract with the academic
affiliate for faculty.
Figure 1.VA Facilities and Medical Schools, with and without Affiliations
Affiliated
Not Affiliated
160
140
28
11
124
130
120
100
80
60
40
7
20
3
22
3
0
VA Medical Centers
VA Independent
Outpatient Clinics
Allopathic Medical
Schools
Osteopathic
Medical Schools
Source: U.S. Department of Veterans Affairs, Office of Academic Affiliations, "Mission of the Office of Academic
Affiliations," http://www.va.gov/oaa/specialfellows/default.asp?p=1, website accessed June 5, 2014.
VA Funding of Physician Training
The VA is the second-largest federal payer for medical training after Medicare, which subsidizes
graduate medical education (GME) at teaching hospitals. Medicare GME payments totaled $10.0
billion in 2014.11 Between FY2010 and FY2014 (estimated) the VA has spent $1.2- $1.8 billion
annually on health professionals training, including but not limited to physician training (see
Figure 2). Funds appropriated for the VA health care system are categorized as either general
purpose funds or specific purpose funds, both of which support some aspects of physician
training. General purpose funds are distributed at the beginning of each fiscal year to be used for
basic care, complex care, adjustments for high cost patients, geographic price adjustment,
research support, equipment, non-recurring maintenance, and education support. Specific purpose
11
U.S. Government Accountability Office, Health Care Workforce: Federally Funded Training Programs in Fiscal
Year 2012, 13-709R, August 15, 2013, http://www.gao.gov/products/GAO-13-709R; and Congressional Budget Office,
Medicare, May 2012, Baseline (estimate), http://www.cbo.gov/sites/default/files/cbofiles/attachments/
43060_Medicare.pdf.
Congressional Research Service
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The Veterans Health Administration and Medical Education: A Fact Sheet
funds are distributed throughout the fiscal year to be used for prosthetics, mental health, homeless
grants and per diem program, state home per diems, transplants, readjustment counseling, medical
facility activations, and clinical trainees.
Figure 2.VA Spending on Health Care Professional Education and Training
(FY2010 – FY2016 Advance Appropriation Request)
(not limited to physicians, dollars in millions)
$2,000
$1,800
$1,600
$1,400
$1,200
Specific Purpose
(direct training costs)
$1,000
General Purpose
(indirect training costs)
$800
$600
$400
$200
$0
FY2010
FY2011
FY2012
FY2013
FY2014
(est)
FY2015
(est)
FY2016
(req)
Source: CRS analysis of VA Budget Justifications.
Notes: Specific purpose funds (direct training costs): “Special Purpose funds that are allocated in the President's
Budget to directly fund the stipends and benefits of VA clinical trainees who rotate through VA medical centers
during the year.” General purpose funds (indirect training costs): “Educational supplement to the Veterans
Equitable Resource Allocation (VERA) model in support of the indirect costs of VA medical centers that have
clinical training programs. These funds help offset costs such as faculty time, education office staffing,
accreditation costs, and space and equipment needs.”
Congressional Research Service
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The Veterans Health Administration and Medical Education: A Fact Sheet
Author Contact Information
Elayne J. Heisler
Analyst in Health Services
eheisler@crs.loc.gov, 7-4453
Congressional Research Service
Erin Bagalman
Analyst in Health Policy
ebagalman@crs.loc.gov, 7-5345
5
operates fellowship training programs in subspecialties that are of high importance to the VA.10
VA Funding of Physician Training
The VA is the second-largest federal payer for medical training after Medicare, which subsidizes graduate medical education (GME) at teaching hospitals. Medicare GME payments totaled $11.2 billion in FY2013.11 The VA spent approximately $1.5 billion in GME training in FY2015. Between FY2010 and FY2014 (estimated) the VA has spent $1.2- $1.8 billion annually on health professionals training, including but not limited to physician training (see Figure 1). Funds appropriated for the VA health care system are divided into general purpose funds and specific purpose funds, both of which support some aspects of physician training. General purpose funds are distributed at the start of the fiscal year to the Veterans Integrated Service Networks (VISNs) and are used in part to fund administrative costs of residency training programs such as salaries of VA instructors in the GME and associated health professional training programs, and space and equipment needs. Specific purpose funds are generally administered centrally and are provided to VA medical facilities to fund, among other things, resident's stipends and fringe benefits.
Figure 1. VA Spending on Health Care Professional Education and Training(FY2010–FY2015)
(not limited to physicians, dollars in millions)
|
Source: CRS analysis of VA Budget Justifications.
Notes: Specific purpose funds (direct training costs): are allocated to directly fund the stipends and benefits of VA clinical trainees who rotate through VA medical centers during the year. General purpose funds (indirect training costs): support costs of VA medical centers that have clinical training programs. These funds help offset costs such as faculty time, education office staffing, accreditation costs, and space and equipment needs.
|
Ongoing GME Expansion
The Veterans Access, Choice, and Accountability Act of 2014 (P.L. 113-146, as amended) required an increase in the number of graduate medical education (GME) physician residency positions by up to 1,500 over a five-year period, beginning July 1 of 2015 through 2019, with an emphasis on primary care, mental health, and other specialties the VA Secretary deems appropriate. As part of this expansion, the VA allocated 204.3 new VA positions for residents that began training in 2015.12 Positions were allocated to 66 facilities in 35 states (positions were also allocated to facilities in the District of Columbia and Puerto Rico). As of July 1, 2015, 162.9 of the 204.3 allocated positions were filled.13
Author Contact Information
[author name scrubbed], Analyst in Health Services
([email address scrubbed], [phone number scrubbed])
[author name scrubbed], Specialist in Veterans Policy
([email address scrubbed], [phone number scrubbed])
Footnotes
| 1.
|
38 U.S.C. §7302.
|
| 2.
|
See U.S. Department of Veterans Affairs, Policy Memorandum No. 2, Subject: Policy in Association of Veteran's Hospitals with Medical Schools, Washington, DC, January 30, 1946, http://www.va.gov/oaa/Archive/PolicyMemo2.pdf.
|
| 3.
|
The VA reports that nearly 70% of VA physicians had trained at the VA prior to their employment. U.S. Department of Veterans Affairs (VA). Office of Academic Affiliations, "Mission of the Office of Academic Affiliations," http://www.va.gov/oaa/specialfellows/default.asp?p=1, website accessed June 5, 2014.
|
| 4.
|
CRS Report R43704, Veterans Access, Choice, and Accountability Act of 2014 (H.R. 3230; P.L. 113-146), by [author name scrubbed] et al.
|
| 5.
|
U.S. Congress, House Committee on Veterans' Affairs, Subcommittee on Health, Healthcare Professionals—Recruitment and Retention, 110th Cong., 1st sess., October 18, 2007 (Washington: GPO, 2008), p. 40.
|
| 6.
|
Drawn from a sample copy of VA Form 10-0094a, "Medical Education Affiliation Agreement Between Department of Veterans Affairs (VA), and A School Of Medicine and its Affiliated Participating Institutions."
|
| 7.
|
Allopathic medical schools grant a Doctor of Medicine degree (M.D.); osteopathic medical schools grant a Doctor of Osteopathic Medicine degree (D.O.).
|
| 8.
|
Veterans Health Administration, Procurement & Logistics Office, The Academic Affiliate Guide to Health Care Resources Contracting with the Department of Veteran's Affairs, 2014.
|
| 9.
|
The VA reports that 99% of its graduate medical education training programs are sponsored by an affiliate. See U.S. Department of Veterans Affairs, Office of Academic Affiliations, "Medical and Dental Education Program," http://www.va.gov/oaa/gme_default.asp.
|
| 10.
|
For more information, see U.S. Department of Veterans Affairs, Office of Academic Affiliations, "Advanced Fellowships and Professional Development," http://www.va.gov/oaa/specialfellows/default.asp.
|
| 11.
|
Data provided by U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations, November 9, 2015.
|
| 12.
|
Allocations of fractions of slots are possible because residents may obtain only a part of their training at a VA medical center. Fractional positions represent a certain number of hours per week (Department of Veterans Affairs, Office of Congressional and Legislative Affairs, email communication, July 1, 2015.)
|
| 13.
|
Office of Academic Affiliations briefing to the Commission on Care, October 6, 2015.
|