By Sandra Basu
WASHINGTON—VA officials told lawmakers that they anticipate filling, by 2024, all of the graduate medical education (GME) positions authorized in a 2014 law.
“We believe within the 10-year milestone we will be able to fill the 1,500 slots,” VHA Deputy Chief Academic Affairs Officer Karen Sanders, MD, told lawmakers at a recent hearing.
The Veterans Access, Choice and Accountability Act of 2014 (VACAA) originally authorized the creation of 1,500 positions over five years, but it was extended for 10 years until 2024 by legislation passed by Congress at the end of 2016. The positions are primarily meant to target mental health and primary care and areas where there is a physician shortage.
So far, VA has filled 547 of the 1,500 GME positions with more than two-thirds of these positions in primary care and psychiatry. Lawmakers questioned whether it will be possible to fill all of these positions.
“I remain concerned that rural and underserved VA facilities that may not have the infrastructure to support GME rotations are not doing more to build capacity or prioritize training for other providers,” said Rep. Ann Kuster (D-NH).
GME was one of the topics discussed at a recent House Committee on Veterans’ Affairs Subcommittee on Oversight and Investigations hearing on the relationship between VA and its academic affiliates.
At the hearing, Sanders explained that it has taken time to build the infrastructure to support GME slots in rural and underserved VA facilities. However, she said the efforts are “bearing fruit.”
Rep. Mark Takano (D-CA) said he didn’t realize it took so long to build up these programs, so that underserved areas could take advantage of these residencies.
“The goal was not to get to 1,500 as fast as we could … if that was the case we probably could have spread them around very fast, within five years, but the goal was really to meet the legislative intent, which was to concentrate on primary care and mental health, which is what the country needs, but also to distribute GME to rural and underserved areas,” Sanders responded.
Meanwhile, Christopher Colenda, MD, MPH, senior adviser on veterans affairs for the Association of American Medical Colleges, told lawmakers that increasing VA GME funding alone will not address the issue, because many of the sponsoring institutions might not be able to afford the increased number of positions.
He said that AAMC encourages Congress and the Trump administration to develop a mechanism that will allow affiliate teaching hospitals that are already at or above their 1997 Medicare GME cap to receive federal financial support for VACAA residents while they are training at a non-VA facility.
He also said that the AAMC endorses a bill, (H.R. 2267), which would allow Medicare to support 15,000 new GME slots over five years, and provides a preference for teaching hospitals that are affiliated with the VA.
“Unfortunately, GME growth at academic affiliates has been stymied by caps on Medicare support,” Colenda said.
The hearing also looked at whether the VA was giving proper oversight to its relationships with affiliates, including the GME program. Subcommittee Chairman Rep. Jack Bergman (R-MI) said that “numerous VA medical centers have no process in place for ensuring that residents and attendings are actually in the VA clinics seeing patients.”
“There is no mechanism for accounting for these doctors’ time and attendance,” Bergman pointed out.
Rep. Phil Roe, MD, (R-TN), chairman of the House Committee on Veterans’ Affairs, also reiterated these concerns and said that affiliates should not be paid, if the residents are not working.
Roe noted, that when members of the House committee’s staff visited one VA facility, they were told that the affiliate had refused to provide documentation of resident attendance and that the facility was afraid of actions that the affiliate might take, if the facility pushed the issue.
“At other facilities, the affiliate did not get paid unless there was proof of attendance, so there appears to be a wide disparity in what should be a consistent process across all facilities,” he said.
Sanders responded that there should not be inconsistencies from facility to facility and that VA has detailed policies that require appropriate documentation before affiliates are paid.
“Our policies are very clear when it comes to the documentation that is necessary to support an invoice for an academic affiliate for resident time and attendance,” she said.
Sanders suggested that determining whether the residents do the work is not an issue, because they are seeing patients and writing notes in the electronic medical record.
“There are multiple oversight processes in the resident-tracking processes,” she said.
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.