Contents

• Background
• The VA's Involvement in Medical Training
• Academic Affiliations
• VA Funding of Physician Training
• Ongoing GME Expansion

Background

Training health care professionals—including physicians¹—is part of the VA's statutory mission.² 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.³ 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.⁴ 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, 2015, through 2019.⁵

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).⁶

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.⁷ During the 2015-2016 academic year, 134 VA medical facilities were affiliated with 135 of 144In 2017, the VA's physician education program included affiliations with 144 of 149 allopathic medical schools and 30 of 33all 34 osteopathic medical schools.⁸ 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.⁹ 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.¹⁰ Specifically, the VA does not operate its own medical schools, but medical students from affiliated institutions may do aone or more clinical rotationrotations 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.¹¹

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 FY2013.¹² Between FY2010 and FY2015FY2017 (est.), the VA has spent $1.46 billion to $1.8913.9 billion annually on health professionals training, including but not limited to physician training (see Figure 1).¹³ 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) andtraining are divided into direct training costs and indirect training costs, both of which support some aspects of physician training. Direct training costs are generally administered centrally and are provided to VA medical facilities to fund, among other things, residents' stipends and fringe benefits. Indirect training costs 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, residents' stipends and fringe benefits.

Figure 1. VA Spending on Health Care Professional Education and Training (FY2010-FY2017FY2018 request) (not limited to physicians, dollars in millions)

Source: CRS analysis of various years of VA Budget Justifications. FY2016 and FY2017FY2017 and FY2018 numbers were obtained from Department of Veterans Affairs, Congressional Submission, FY2017 Funding and FY2018 Advance Appropriations Request, Vol. 2, Medical Programs and Information Technology Programs, p. VHA-240. FY2018 Congressional Submission, Medical Programs and Information Technology Programs, vol,. 2 of 4, May 2017 p. VHA-136. Numbers for previous fiscal years were obtained from similar VA budget submissions to Congress for FY2012-FY2015FY2017; the number for each fiscal year is taken from the budget submission two years later (e.g., the FY2015FY2016 number is from the FY2017FY2018 budget submission). Notes: Specific purpose funds (directEst.=estimated; req.=requested. 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 (indirectIndirect 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. Until the FY2018 Congressional Budget Submission, the VA presented "direct" and "indirect" training costs as specific-purpose funding and general-purpose funding, respectively, under the Veterans Equitable Resource Allocation (VERA) allocation methodology. Beginning with the FY2018 Congressional Submission funding is depicted as "direct" and "indirect" training costs.

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 residencyGME positions by up to 1,500 over a five10-year period,¹⁵ beginning July 1, 2015, through 20192024, with an emphasis on primary care, mental health, and other specialties the VA Secretary deems appropriate. As part of this expansion, the VA has allocated 388.4547 new VA positions for residents that began training in either 2015 or 2016. Two-thirds of these new positions were in primary care or mental health.¹⁴; 70% were in primary care or mental health. The remaining new positions were in a specialty designated as a "critical need" by the VA Secretary.¹⁶ The legislation also required that the expansion focus on creating new programs at VA facilities where there had not previously been GME training and the new positions be awarded for training in rural or otherwise underserved areas. As part of the GME expansion, VA's OAA identified VA facilities without GME programs and has worked to establish, or begin the planning process to establish, GME programs at all but 4 of the 22 sites that the VA identified as not having GME.¹⁷ The VA's objective is to add an additional 953 additional GME positions by 2025.¹⁸

Appendix. VA Health Professional Training

The Veteran's Health Administration facilities are the largest sites for health professional training in the United States. Physicians, including medical students, residents, and fellows, are the largest type of health professionals trained, but the VA trains over 40 types of health professionals. In doing so, it partners with over 1,800 unique colleges and universities, including those that serve racial and ethnic minority groups who are traditionally underrepresented in the health professions (such as Historically Black Colleges and Universities, and Tribal colleges).

The table below presents seveneight years of data on VA's health professional training

Over the past fivesix years, the VA has also expanded its mental health training. Specifically, since 20132012, the VA has supported an additional 650750 trainees in various mental health professions. This represents facilities with existing programs that grew in program size and new facilities that commenced mental health training. Trainees were added in a variety of fields, including

• clinical pastoral education,
licensed professional mental health counseling,
• marriage and family counseling,
• mental health nursing,
• occupational therapy,
• pastoral counseling,
• pharmacy,
• physician assistant,
psychiatry,
• psychology, and
• social work.

Author Contact Information

Footnotes

U.S. Government Accountability Office, Veterans Health Administration: Better Data and Evaluation Could Help Improve Physician Staffing, Recruitment, and Retention Strategies, GAO 18-124, October 19, 2017, p. 8.