GME Enhancement

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					 VA Funding of Graduate
   Medical Education
         August 28, 2010
 Family Medicine Working Grooup
    Barbara K. Chang, MD, MA
VHA Office of Academic Affiliations
VA Milestones
   Veterans Administration
    established as an independent
    federal agency on July 21, 1930.
   Department of Veterans
    Affairs became cabinet level on
    March 15, 1989.
   Veteran's Health Care
    Eligibility Reform Act of
    1996 (PL 104-262)
   Veterans Millennium Health
    Care and Benefits Act of
    1999 (PL 106-117)


        2
Partnership with Academic Medicine

  Policy Memorandum No 2.
  Establishing Teaching Affiliations
  Subject: Policy in Association of
    Veterans’ Hospitals with Medical
    Schools
  January 30, 1946




                     3
Veterans Health Administration (VHA)
  Largest integrated healthcare system in
   US (FY 09 data):
   • VA Hospitals: 153
   • Outpatient Clinic Total: 956
       Hospital Based Outpatient Clinics (HBOC) 153
       Independent Outpatient Clinics (IOC) 6
       Mobile Outpatient Clinics (MOC) 9
       Community Based Outpatient Clinics (CBOC) 788
   • 8 M enrollees
   • 5.1 M patient treated annually
   • ~200K FTE employees (~65K health care,
     including ~17K physicians)


                          4
Overview: VA Trainee ‘Workforce’
 ~100K trainees annually
  • GME & UME – about 50%
  • Associated health education (40K+)
  • Advanced (non-accredited) fellowships

 Annual budget
  • ~$0.6B (direct costs) & $0.6B (indirects)
  • 80% devoted to GME
  • 2nd only to CMS (Medicare & Medicaid) in
    support of GME

                      5
         GME Scope in VA
 >36,000 residents rotate
    through 124 of 153 VA Hospitals & 2/6
     IOCs
    representing 1/3rd all US residents
    representing 37% VA physician workforce
    60% VA staff physicians are former
     trainees
 Affiliations with 107 of 129 US
  allopathic & 15 of 26 osteopathic
  medical schools


                     6
               Scope of GME in VA
 >36,000 physician residents –
  representing ~30% of all US residents –
  receive training in VA annually
 2,000+ ACGME-accredited programs
 Representing 79 different medical
  specialties & subspecialties
 Prior to GME Enhancement,
  VA supported about 8,900
  individual resident salary lines
   (8.5% of US) – now about 10K slots
 99% of VA programs are sponsored in the name of
  affiliates

                         7
      VA’s Transformative Initiatives:
         Pt.Centered Primary Care
 New Model:
 • Patient-Centric/Team-Based
 • Active collaboration &
   communication among team
   inclusive of patient/family
   throughout workflow




Current Model:
• Provider/Professional-Centric
• CPRS Facilitates mostly “Do”
  Actions



                                  8      8
VA involvement in Internal Medicine –
          ~3,300 positions in AY 10-11
               Est % US IM residents, VA rotations
               % IM of total VA resident positions

 70%           % VA IM positions of total US IM positions

 60%

 50%

 40%

 30%

 20%

 10%

  0%
       20       20      20      20      20          20      20      20      20      20      20
          01       02      03      04      05          06      07      08      09      10      11

                                                9
VA involvement in Family Medicine:
         Ten-year history
                                         160
  VA Family Medicine Resident Positons

                                         140

                                         120

                                         100

                                         80

                                         60

                                         40

                                         20

                                          0
                                               01

                                                     02

                                                           03

                                                                 04

                                                                       05

                                                                             06

                                                                                   07

                                                                                         08

                                                                                               09

                                                                                                     10
                                           20

                                                    20

                                                          20

                                                                20

                                                                      20

                                                                            20

                                                                                  20

                                                                                        20

                                                                                              20

                                                                 Academic Year (AY)                 20
                                                                             10
VA involvement in Family Medicine –
          ~100 positions in AY 10-11
               % US FM residents rotating at VA
               % VA supported FM resident positions
 5.0%          % FM of total VA resident positions
 4.5%
 4.0%
 3.5%
 3.0%
 2.5%
 2.0%
 1.5%
 1.0%
 0.5%
 0.0%
        2006     2007      2008      2009      2010
                            11
VA involvement in Family Medicine –
          ~100 positions in AY 10-11
               % US FM residents rotating at VA
               % VA supported FM resident positions
 5.0%          % FM of total VA resident positions
 4.5%
 4.0%
 3.5%
 3.0%
 2.5%
 2.0%
 1.5%
 1.0%
 0.5%
 0.0%
        2006     2007      2008      2009      2010
                            12
How does VA fund GME positions?
 Annual resident allocation cycle
  • Base (permanent) positions apply for in
    October & approved by early Dec. in time for
    Match (NRMP)
  • Filled positions allocated post-Match (mid-to
    late March report) – final approvals, early May
  • Temporary positions may be available if
    unfilled
 Historic 'base' vs. current needs
  • Requires a planning process – with GMEC
  • Involvement of the DIO, the Program Director, the
    VA Site Director, & the VA Designated Education
    Officer (DEO)
                         13
What GME activities can VA fund?
 Resident educational activities while on
  assignment to the VA
  • Clinical, didactic & scholarly activities
  • Cannot fund off-site activities, except for
    didactic and continuity clinics if reciprocal
    plus a few other exceptions
 Accredited programs & training years
  • i.e., non-accredited programs & years may
   not be funded
  • However, VA can fully fund accredited
    fellowship years, unlike Medicare

                        14
                         VA vs. Medicare:
                     Summary Comparison
       Cost center – who funds                      VA               Medicare
                what?
    Inpatient rotations                   Yes                  Yes
    Outpatient rotations                  Yes                  It all depends*
    Scholarly activities, including
                                          Yes                  No
    research
    Academic coursework (e.g.,
                                          No                   No
    MPH degree)
    Didactics & orientation               Yes                  No
                                          No, with limited     No (receiving hospital
    Off-site rotations
                                          exceptions**         can claim)
                                                               Yes, half direct
    Subspecialty fellowship years Yes, fully
                                                               costs
                                                               Direct costs intended
    Resident supervision                  Staff physicians     to cover (but may be
                                                               inadequate )

 *Requires significant paperwork. Healthcare reform legislation may facilitate.
**Reciprocal funding of continuity clinics; ‘educational details’ possible for training
required by ACGME, but not available at any participating hospital.

                                               15
                Indirect Costs
 VA: VERA Educational supplement
  • Currently $71.2K/physician resident - as surrogate
    for all trainees
  • Goes to the VISN (most say they ‘pass through’)
  • Medical care funds – not ‘ear-marked’
 VA: cannot pay indirect costs to affiliates via
  disbursement agreement
 Medicare IDC (indirect costs)
  • Go to the hospital sponsor to offset medical care
    costs of teaching hospital (sicker patients, etc.)
 Medicare DSH (disproportionate share)
   • Goes to teaching hospitals with higher % indigent
     patients
 NOTE: neither Medicare nor VA directly funds true
  indirect costs of education
                           16
 VA GME Payment Mechanisms
 Direct salary payment - doesn't work
  well with rotating residents
 Disbursement Agreements
  • Statutory authority to pay residents
    stipends & benefits indirectly under
    disbursement agreements
  • Must have an affiliation agreement
  • New disbursement agreement
  • Planning process & good communication
    with affiliates is key


                     17
Revised Policy: Underlying philosophy
 Resident positions within approved
  allocations should be reimbursed to
  the extent that assigned residents
  engage in VA-approved educational
  activities
 VA is not paying for residents’
  “service” or “work”, but is
  participating in support of their
  training
 Still cannot fund administrative
  support of resident programs through
  disbursement agreements
                  18
            Policy Definitions
          Old                      New
Timekeeping              Record keeping
Training & related       Educational activities
services
Timecards/time sheets Certified educational
                      activity records
Salary                Stipend
Duty day or duty week Duty month or rotation
Affiliated institution or (Affiliated) Sponsoring
Index hospital            institution or its
                          Disbursing Agent

                        19
Accounting for residents who are less
    than fully-assigned to the VA
“Full-time/part-time” designations are
  now considered as:
  • “Full”, where the primary assignment
    is to the VA & no other institution
  • “Split” assignment, if a resident’s
    activities are divided between the VA
    & another participating institution
    Sample activity schedules (by program)
     are to be reviewed by the Program
     Director & VA Site Director, who decides
     on the % at the VA, based upon the total
     activity of the resident – VA DEO concurs
                     20
  Background
 History: Federally Chartered Advisory
  Committee recommendations and
  approval by the VA Secretary (fall 2005)
 5-year initiative to restore VA-funded
  positions to historic levels of 10-11% of
  US total physician resident positions
  • ~2,000 new positions to be added to the
    8,900 pre-existing positions over 5 years
  • Estimated cost of about $0.25B
  • RFP process begun 2006 for AY 2007-08
  • First major expansion of VA GME in >15 yrs
                      21
 Goals of VA’s GME Enhancement

 To address physician workforce shortages
  • by expanding resident positions in specialties of
    greatest need to US veterans and the Nation
 To address the uneven geographic
  distribution of residents
  • to improve access to care
 To foster innovative models of education
  • while enhancing VA’s leadership role in US GME
 Add about 2,000 additional resident
  positions
  • To a base of about 8,900 in AY 2005-06 – goal of
    national share 10-11%
                         22
       Allocation Methodology
 Competitive application process
  in response to RFPs (local VA to OAA)
 Proposals evaluated on:
  • Quality of the training experience
    Peer review panel of VHA GME
     experts ranked applications against
     criteria
  • Capacity to train
    Patient care services
     delivered by residents


                        23
        4 GME Enhancement RFPs
 Critical Needs & Emerging Specialties (2006 –
 present)
  • Facility-identified needs
  • Facilities w/ ≥ 40 residents eligible
 New Affiliations & New Sites of VA Care (2006 –
 present)
  • New hospitals or affiliations, OPCs, & Community-
    based Outpt Clinics (CBOCs)
 Educational Innovation (since 2007 – present)
  • Innovative approaches to education & care delivery
    – exemplary accreditation status
 Rural Health Training (2009)
  • Trainees in rural or highly rural sites
                            24
       Overall Outcomes:
    Phases 1-4 (2006-09)
   1,221 Positions added
   71 different specialties
   1,106 programs
   87 VA facilities
   Phase 4 only:
    • 254 GME positions @ 49 facilities
      (277 requested by 51 facilities)
    • 15 AH positions (7 EI, 8 RHT)


                  25
Impact of GME Enhancement




            26
  Approved Resident positions by RFP


                                                GME Positions (2006-09)
             RFP
                               Phase 1        Phase 2   Phase 3    Phase 4   Totals
Critical Needs & Emerging
Specialties                     300            294        212        147      953
New Affiliations & New Sites     42             41         50         76      209
Educational Innovation         (N/A)            21         7          10      38
Rural Health Training          (N/A)          (N/A)      (N/A)        21      21
Total                             342            356      269        254     1221




                                         27
Shift of Approval to “New Sites”




               28
 Distribution by Specialty Grouping:
  GME Enhancement New Positions

                                              %
     Specialty Grouping          Positions
                                             Total
Generalist                             245    20%
Medicine Subspecialty                  323    26%
Mental Health                          169    14%
Surgery & Related                      186    15%
Specialty Other                        206    17%
Ancillary Diagnostic                    64     5%
Rehabilitation                          29     2%
                        Total:       1,221   100%


                          31
% Distribution of TOTAL VA positions
at baseline & post-GME Enhancement




                 32
Impact of GME Enhancement on Total Allocations
  of Pipeline, Fellowship, & Specialty Positions




                       33
Common Foci: Educational Innovation
         Patient-centered care
         Patient safety & QI
         Interdisciplinary or
           “collaborative” care
         Continuity of care
         Greater ambulatory care
         Chronic care management
         Simulation
         Telemedicine
         Competency/proficiency
         Professionalism
                  34
       Summary/Conclusions
 VA is attempting to expand & change
  GME to meet the needs of VA & the US
 Our emphasis is on educational quality
  & capacity to train
 Geographic distribution has favored
  the under-represented areas in GME
 Challenges:
  • to impact entry-level positions (in pipeline
    programs), esp in GIM &
  • to introduce more innovation into
    educational programs

                      35

				
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