The Veterans Health Administration and Medical Education: In Brief

September 21, 2016 (R43587)

Contents

Figures

Tables

Appendixes

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

Table 1. VA Medical Training at the Trainee Level (Academic Year 2015-2016)

Trainee Type

Description

Number in Training

 

 

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

24,283

112,622b

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).

43,013

118,366

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.)

387

20,779

Sources: VA data from U.S. Department of Veterans Affairs. Office of Academic Affiliations, "2015 Statistics: Health Professions Trainees," email from the VA's Office of Academic Affiliations, June 3, 2016. Medical school enrollment data from the Association of American Medical Colleges, "Table B-1.2: Total Enrollment at U.S. Medical School and Sex, 2011-2012 through 2015-2016," and American Association of Colleges of Osteopathic Medicine, "Preliminary Enrollment Report Fall 2015"; these data are totaled to determine the total number of medical students. Medical Resident and Fellow data from Sarah E. Brotherton and Sylvie I. Etzel, "Graduate Medical Education, 2014-2015," Journal of the American Medical Association, vol. 314, no. 22 (December 8, 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.

b. The total number of medical students is composed of medical students enrolled in allopathic schools of medicine (i.e., MD granting schools) and osteopathic schools of medicine (i.e., DO granting schools).

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 144 allopathic medical schools and 30 of 33 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 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.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 FY2015, the VA has spent $1.46 billion to $1.89 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) 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, residents' stipends and fringe benefits.

Figure 1. VA Spending on Health Care Professional Education and Training
(FY2010-FY2017 request)

(not limited to physicians, dollars in millions)

Source: CRS analysis of various years of VA Budget Justifications. FY2016 and FY2017 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. Numbers for previous fiscal years were obtained from similar VA budget submissions to Congress for FY2012-FY2015; the number for each fiscal year is taken from the budget submission two years later (e.g., the FY2015 number is from the FY2017 budget submission).

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, 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 has allocated 388.4 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

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 seven years of data on VA's health professional training

Table A-1. VA Health Professional Training, 2009-2015

 

2009

2010

2011

2012

2013

2014

2015

Advanced Fellows (Medicine)

175

239

288

297

253

311

387

Associated Healtha

23,483

23,871

24,608

25,122

26,121

26,454

26,135

Dental Residents & Students

1,280

1,267

1,231

1,195

1,397

1,398

986

Physician Residents

36,410

36,745

36,816

37,809

40,420

41,697

43,013

Medical Students

20,245

20,516

21,502

20,218

21,541

23,031

24,283

Nursing Traineesb

33,092

32,662

32,349

32,859

29,067

28,086

28,389

Non-Health Professionalsc

N/A

N/A

N/A

N/A

N/A

359

359

Total

114,685

115,300

116,794

117,500

118,799

121,345

123,552

Source: Email communication with the U.S. Department of Veterans Affairs. Office of Academic Affiliations, June 3, 2016.

Notes: The VA aggregates these data based on information it receives from the "Health Services Training Report," which each facility completes at the conclusion of each fiscal year. Data are not unduplicated (i.e., it is possible, though unlikely, for trainees to have trained at more than one VA facility and therefore be counted more than once in these data).

a. Includes all health disciplines that are not medicine, dentistry, or nursing (e.g., psychologists, pharmacists, and social workers).

b. Includes graduate and undergraduate level trainees.

c. Includes individuals in professions such as engineering, information technology, or finance.

Over the past five years, the VA has also expanded its mental health training. Specifically, since 2013, the VA has supported an additional 650 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

Author Contact Information

[author name scrubbed], Specialist in Health Services ([email address scrubbed], [phone number scrubbed])
[author name scrubbed], Specialist in Veterans Policy ([email address scrubbed], [phone number scrubbed])

Footnotes

1.

This report focuses on physician training; information on the full complement of VA health professional training is available in this report's appendix.

2.

38 U.S.C. §7302.

3.

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.

4.

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.

5.

CRS Report R43704, Veterans Access, Choice, and Accountability Act of 2014 (H.R. 3230; P.L. 113-146), by [author name scrubbed] et al.

6.

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.

7.

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."

8.

Allopathic medical schools grant a Doctor of Medicine degree (M.D.); osteopathic medical schools grant a Doctor of Osteopathic Medicine degree (D.O.). The 33 osteopathic medical schools operate programs at 48 locations; for more information, see American Association of Colleges of Osteopathic Medicine, "College of Osteopathic Medicine—Admissions Offices," http://www.aacom.org/docs/default-source/cib/2017_com-map.pdf?sfvrsn=12.

9.

Veterans Health Administration, Procurement & Logistics Office, The Academic Affiliate Guide to Health Care Resources Contracting with the Department of Veteran's Affairs, 2014.

10.

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.

11.

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.

12.

See CRS Report R44376, Federal Support for Graduate Medical Education: An Overview, coordinated by [author name scrubbed].

13.

Department of Veterans Affairs, Congressional Submission, FY 2017 Funding and FY 2018 Advance Appropriations Request, Vol. 2, Medical Programs and Information Technology Programs, p. VHA-240.

14.

Department of Veterans Affairs, Office of Congressional and Legislative Affairs, email communication, June 3, 2016. 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.