The Veterans Health Administration and Medical Education: A Fact Sheet

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 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

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 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.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

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Footnotes