User login
Graduate Medical Education Financing in the US Department of Veterans Affairs
The US Department of Veterans Affairs (VA) has partnered with academic medical centers and programs since 1946 to provide clinical training for physician residents. Ranking second in federal graduate medical education (GME) funding to the Centers for Medicare and Medicaid Services (CMS), the $850 million VA GME budget annually reimburses > 250 GME-sponsoring institutions (affiliates) of 8000 GME programs for the clinical training of 49,000 individual residents rotating through > 11,000 full-time equivalent (FTE) positions.1 The VA also distributes $1.6 billion to VA facilities to offset the costs of conducting health professions education (HPE) (eg, facility infrastructure, salary support for VA instructors and preceptors, education office administration, and instructional equipment).2 The VA financial and educational contributions account for payment of 11% of resident positions nationally and allow academic medical centers to be less reliant on CMS GME funding.3,4 The VA contributions also provide opportunities for GME expansion,1,5,6 educational innovations,5,7 interprofessional and team-based care,8,9 and quality and safety training.10,11 The Table provides a comparison of CMS and VA GME reimbursability based on activity.
GME financing is complex, particularly the formulaic approach used by CMS, the details of which are often obscured in federal regulations. Due to this complexity and the $16 billion CMS GME budget, academic publications have focused on CMS GME financing while not fully explaining the VA GME policies and processes.4,12-14 By comparison, the VA GME financing model is relatively straightforward and governed by different statues and VA regulations, yet sharing some of the same principles as CMS regulations. Given the challenges in CMS reimbursement to fully support the cost of resident education, as well as the educational opportunities at the VA, the VA designs its reimbursement model to assure that affiliates receive appropriate payments.4,12,15 To ensure the continued success of VA GME partnerships, knowledge of VA GME financing has become increasingly important for designated institutional officers (DIOs) and residency program directors, particularly in light of recent investigations into oversight of the VA’s reimbursement to academic affiliates.
VA AUTHORITY
While the VA’s primary mission is “to provide a complete hospital medical service for the medical care and treatment of veterans,”early VA leaders recognized the importance of affiliating with the nation’s academic institutions.19 In 1946, the VA Policy Memorandum Number 2 established a partnership between the VA and the academic medical community.20 Additional legislation authorized specific agreements with academic affiliates for the central administration of salary and benefits for residents rotating at VA facilities. This process, known as disbursement, is an alternative payroll mechanism whereby the VA reimburses the academic affiliate for resident salary and benefits and the affiliate acts as the disbursing agent, issuing paychecks to residents.21,22
Resident FUNDING
By policy, with rare exceptions, the VA does not sponsor residency programs due to the challenges of providing an appropriate patient mix of age, sex, and medical conditions to meet accreditation standards.4 Nearly all VA reimbursements are for residents in affiliate-sponsored programs, while just 1% pays for residents in legacy, VA-sponsored residency programs at 2 VA facilities. The VA budget for resident (including fellows) salary and benefits is managed by the VA Office of Academic Affiliations (OAA), the national VA office responsible for oversight, policy, and funding of VA HPE programs.
Resident Salaries and Benefits
VA funding of resident salary and benefits are analogous with CMS direct GME (DGME), which is designed to cover resident salary and benefits costs.4,14,23 CMS DGME payments depend on a hospital’s volume of CMS inpatients and are based on a statutory formula, which uses the hospital’s resident FTE positions, the per-resident amount, and Medicare’s share of inpatient beds (Medicare patient load) to determine payments.12 The per-resident amount is set by statute, varies geographically, and is calculated by dividing the hospital’s allowable costs of GME (percentage of CMS inpatient days) divided by the number of residents.12,24
By comparison, the VA GME payment reimburses for each FTE based on the salary and benefits rate set by the academic affiliate. Reimbursement is calculated based on resident time spent at the VA multiplied by a daily salary rate. The daily salary rate is determined by dividing the resident’s total compensation (salary and benefits) by the number of calendar days in an academic year. Resident time spent at the VA facility is determined by obtaining rotation schedules provided by the academic affiliate and verifying resident clinical and educational activity during scheduled rotations.
Indirect Medical Education Funding
In addition to resident salary and benefits, funds to offset the cost of conducting HPE are provided to VA facilities. These funds are intended to improve and maintain necessary infrastructure for all HPE programs not just GME, including education office administration needs, teaching costs (ie, a portion of VA preceptors salary), and instructional equipment.
The Veterans Equitable Resource Allocation (VERA) is a national budgeting process for VA medical facilities that funds facility operational needs such as staff salary and benefits, infrastructure, and equipment.2 The education portion of the VERA, the VERA Education Support Component (VESC), is not managed by the OAA, but rather is distributed through the VERA model to the general budget of VA facilities hosting HPE (Figure). VESC funding in the VA budget is based on labor mapping of physician time spent in education; other labor mapping categories include clinical care, research, and administration. VA facility VESC funding is calculated based on the number of paid health profession trainees (HPTs) from all professions, apportioned according to the number of FTEs for physician residents and VA-paid HPTs in other disciplines. In fiscal year 2024, VA facilities received $115,812 for each physician resident FTE position and $84,906 for each VA-paid, non-GME FTE position.
The VESC is like CMS's indirect GME funding, termed Indirect Medical Education (IME), an additional payment for each Medicare patient discharged reflecting teaching hospitals’ higher patient care costs relative to nonteaching hospitals. Described elsewhere, IME is calculated using a resident-to-bed ratio and a multiplier, which is set by statute.4,25 While IME can be used for reimbursement for some resident clinical and educational activities(eg, research), VA VESC funds cannot be used for such activities and are part of the general facility budget and appropriated per the discretion of the medical facility director.
ESTABLISHING GME PARTNERSHIPS
An affiliation agreement establishes the administrative and legal requirements for educational relationships with academic affiliates and includes standards for conducting HPE, responsibilities for accreditation standards, program leadership, faculty, resources, supervision, academic policies, and procedures. The VA uses standardized affiliation agreement templates that have been vetted with accrediting bodies and the VA Office of General Counsel.
A disbursement agreement authorizes the VA to reimburse affiliates for resident salary and benefits for VA clinical and educational activities. The disbursement agreement details the fiscal arrangements (eg, payment in advance vs arrears, salary, and benefit rates, leave) for the reimbursement payments. Veterans Health Administration (VHA) Directive 1400.05 provides the policy and procedures for calculating reimbursement for HPT educational activities.26
The VA facility designated education officer (DEO) oversees all HPE programs and coordinates the affiliation and disbursement agreement processes.27 The DEO, affiliate DIO, residency program director, and VA residency site director determine the physician resident FTE positions assigned to a VA facility based on educational objectives and availability of educational resources at the VA facility, such as patient care opportunities, faculty supervisors, space, and equipment. The VA facility requests for resident FTE positions are submitted to the OAA by the facility DEO.
Once GME FTE positions are approved by the OAA, VA facilities work with their academic affiliate to submit the physician resident salary and benefit rate. Affiliate DIOs attest to the accuracy of the salary rate schedule and the local DEO submits the budget request to the OAA. Upon approval, the funds are transferred to the VA facility each fiscal year, which begins October 1. DEOs report quarterly to the OAA both budget needs and excesses based on variations in the approved FTEs due to additional VA rotations, physician resident attrition, or reassignment.
Resident Position Allocation
VA GME financing provides flexibility through periodic needs assessments and expansion initiatives. In August and December, DEOs collaborate with an academic affiliate to submit reports to the OAA confirming their projected GME needs for the next academic year. Additional positions requests are reviewed by the OAA; funding depends on budget and the educational justification. The OAA periodically issues GME expansion requests for proposal, which typically arise from legislation to address specific VA workforce needs. The VA facility DEO and affiliate GME leaders collaborate to apply for additional positions. For example, a VA GME expansion under the Veterans Access, Choice, and Accountability Act of 2014 added 1500 GME positions in 8 years for critically needed specialties and in rural and underserved areas.5 The Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act of 2018 authorized a pilot program for VA to fund residents at non-VA facilities with priority for Indian Health Services, Tribes and Tribal Organizations, Federally Qualified Health Centers, and US Department of Defense facilities to provide access to veterans in underserved areas.6
The VA GME financing system has flexibility to meet local needs for additional resident positions and to address broader VA workforce gaps through targeted expansion. Generally, CMS does not fund positions to address workforce needs, place residents in specific geographic areas, or require the training of certain types of residents.4 However, the Consolidated Appropriations Act of 2021 has provided the opportunity to address rural workforce needs.28
Reimbursement
The VA provides reimbursement for clinical and educational activities performed in VA facilities for the benefit of veterans as well as research, didactics, meetings and conferences, annual and sick leave, and orientation. The VA also may provide reimbursement for educational activities that occur off VA grounds (eg, the VA proportional share of a residency program’s didactic sessions). The VA does not reimburse for affiliate clinical duties or administrative costs, although a national policy allows VA facilities to reimburse affiliates for some GME overhead costs.29
CMS similarly reimburses for residency training time spent in patient care activities as well as orientation activities, didactics, leave, and, in some cases, research.4,30,31 CMS makes payments to hospitals, which may include sponsoring institutions and Medicare-eligible participating training sites.4,30,31 For both the VA and CMS, residents may not be counted twice for reimbursement by 2 federal agencies; in other words, a resident may not count for > 1 FTE.4,30-32
GME Oversight
VA GME funding came under significant scrutiny. At a 2016 House Veterans Affairs Committee hearing, Representative Phil Roe, MD (R-Tennessee), noted that no process existed at many VA facilities for “determining trainee presence” and that many VA medical centers had “difficulty tracking resident rotations”16 A VA Office of the Inspector General investigation recommended that the VA implement policies and procedures to improve oversight to “ensure residents are fully participating in educational activities” and that the VA is “paying the correct amount” to the affiliate.17 A 2020 General Accountability Office report outlined unclear policy guidance, incomplete tracking of resident activities, and improper fiscal processes for reimbursement and reconciliation of affiliate invoices.18
In response, the OAA created an oversight and compliance unit, revised VHA Directive 1400.05 (the policy for disbursement), and improved resident tracking procedures.26 The standard operating procedure that accompanied VHA Directive 1400.05 provides detailed information for the DEO and VA facility staff for tracking resident clinical and educational activities. FTE counts are essential to both VA and CMS for accurate reimbursement. The eAppendix and the Table provide a guide to reimbursable activities in the VA for the calculation of reimbursement, with a comparison to CMS.33,34 The OAA in cooperation with other VA staff and officers periodically conducts audits to assess compliance with disbursement policy and affiliate reimbursement accuracy.
In the VA, resident activities are captured on the VA Educational Activity Record, a standardized spreadsheet to track activities and calculate reimbursement. Each VA facility hosting resident physicians manually records resident activity by the half-day. This process is labor intensive, involving both VA and affiliate staff to accurately reconcile payments. To address the workload demands, the OAA is developing an online tool that will automate aspects of the tracking process. Also, to ensure adequate staffing, the OAA is in the process of implementing an office optimization project, providing standardized position descriptions, an organizational chart, and staffing levels for DEO offices in VA facilities.
Conclusions
This report describes the key policies and principles of VA GME financing, highlighting the essential similarities and differences between VA and CMS. Neither the VA nor CMS regulations allow for reimbursement for > 1 FTE position per resident, a principle that underpins the assignment of resident rotations and federal funding for GME and are similar with respect to reimbursement for patient care activities, didactics, research, orientation, and scholarly activity. While reimbursable activities in the VA require physical presence and care of veteran patients, CMS also limits reimbursement to resident activities in the hospital and approved other settings if the hospital is paying for resident salary and benefits in these settings. The VA provides some flexibility for offsite activities including didactics and, in specific circumstances, remote care of veteran patients (eg, teleradiology).
The VA and CMS use different GME financing models. For example, the CMS calculations for resident FTEs are complex, whereas VA calculations reimburse the salary and benefits as set by the academic affiliate. The VA process accounts for local variation in salary rates, whereas the per-resident amount set by CMS varies regionally and does not fully account for differences in the cost of living.24 Because all patients in VA facilities are veterans, VA calculations for reimbursement do not involve ratios of beds like the CMS calculations to determine a proportional share of reimbursement. The VA GME expansion tends to be more directed to VA health workforce needs than CMS, specifying the types of programs and geographic locations to address these needs.
The VA regularly reevaluates how affiliates are reimbursed for VA resident activity, balancing compliance with VA policies and the workload for VA and its affiliates. The VA obtains input from key stakeholders including DEOs, DIOs, and professional organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.35,36
Looking ahead, the VA is developing an online tool to improve the accuracy of affiliate reimbursement. The VA will also implement a standardized staffing model, organizational structure, and position descriptions for DEO offices. These initiatives will help reduce the burden of tracking and verifying resident activity and continue to support the 77-year partnership between VA and its affiliated institutions.
1. Klink KA, Albanese AP, Bope ET, Sanders KM. Veterans Affairs graduate medical education expansion addresses US physician workforce needs. Acad Med. 2022;97(8):1144-1150. doi:10.1097/ACM.0000000000004545
2. Andrus CH, Johnson K, Pierce E, Romito PJ, Hartel P, Berrios‐Guccione S, Best W. Finance modeling in the delivery of medical care in tertiary‐care hospitals in the Department of Veterans Affairs. J Surg Res. 2001;96(2):152-157. doi:10.1006/jsre.1999.5728
3. Petrakis IL, Kozal M. Academic medical centers and the U.S. Department of Veterans Affairs: a 75-year partnership influences medical education, scientific discovery, and clinical care. Acad Med. 2022;97(8):1110-1113. doi:10.1097/ACM.0000000000004734
4. Heisler EJ, Mendez BH, Mitchell A, Panangala SV, Villagrana MA. Federal support for graduate medical education: an overview (R44376). Congressional Research Service report R44376; version 11. Updated December 27, 2018. Accessed March 2, 2024. https://crsreports.congress.gov/product/pdf/R/R44376/11
5. Chang BK, Brannen JL. The Veterans Access, Choice, and Accountability Act of 2014: examining graduate medical education enhancement in the Department of Veterans Affairs. Acad Med. 2015;90(9):1196-1198. doi:10.1097/ACM.0000000000000795
6. Albanese AP, Bope ET, Sanders KM, Bowman M. The VA MISSION Act of 2018: a potential game changer for rural GME expansion and veteran health care. J Rural Health. 2020;36(1):133-136. doi:10.1111/jrh.12360
7. Lypson ML, Roberts LW. Valuing the partnership between the Veterans Health Administration and academic medicine. Acad Med. 2022;97(8):1091-1093. doi:10.1097/ACM.0000000000004748
8. Harada ND, Traylor L, Rugen KW, et al. Interprofessional transformation of clinical education: the first six years of the Veterans Affairs Centers of Excellence in Primary Care Education. J Interprof Care. 2023;37(suppl 1):S86-S94. doi:10.1080/13561820.2018.1433642
9. Harada ND, Rajashekara S, Sansgiry S, et al. Developing interprofessional primary care teams: alumni evaluation of the Department of Veterans Affairs Centers of Excellence in Primary Care Education Program. J Med Educ Curric Dev. 2019;6:2382120519875455. doi:10.1177/2382120519875455
10. Splaine ME, Ogrinc G, Gilman SC, et al. The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars. Acad Med. 2009;84(12):1741-1748. doi:10.1097/ACM.0b013e3181bfdcef
11. Watts BV, Paull DE, Williams LC, Neily J, Hemphill RR, Brannen JL. Department of Veterans Affairs chief resident in quality and patient safety program: a model to spread change. Am J Med Qual. 2016;31(6):598-600. doi:10.1177/1062860616643403
12. He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: a narrative review. Am J Surg. 2021;221(1):65-71. doi:10.1016/j.amjsurg.2020.06.007
13. Villagrana M. Medicare graduate medical education payments: an overview. Congressional Research Service report IF10960. Updated September 29, 2022. Accessed March 2, 2024. https://crsreports.congress.gov/product/pdf/IF/IF10960
14. Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Eden J, Berwick DM, Wilensky GR, eds. Washington, DC: National Academies Press; 2014. doi:10.17226/18754
15. Physician workforce: caps on Medicare-funded graduate medical education at teaching hospitals. Report to congressional requesters. GAO-21-391. May 21, 2021. Accessed March 1, 2024. https://www.gao.gov/assets/gao-21-391.pdf
16. VA and Academic Affiliates: Who Benefits? Hearing Before the Subcommittee on Oversight and Investigations of the Committee on Veterans’ Affairs, 114th Cong, 2nd Sess (2016). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CHRG-115hhrg29685/html/CHRG-115hhrg29685.htm
17. US Department of Veterans Affairs, Office of Inspector General (OIG). Veterans Health Administration. Review of resident and part-time physician time and attendance at the Oklahoma City VA Health Care System. OIG report 17-00253-93. March 28, 2018. Accessed March 1, 2024. https://www.oversight.gov/sites/default/files/oig-reports/VAOIG-17-00253-93.pdf
18. VA health care: actions needed to improve oversight of graduate medical education reimbursement. Report to the ranking member, Committee on Veterans’ Affairs, House of Representatives. GAO-20-553. July 2020. Accessed March 1, 2024. https://www.gao.gov/assets/710/708275.pdf
19. Functions of Veterans Health Administration: in general, 38 USC §7301 (2022). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/USCODE-2022-title38/pdf/USCODE-2022-title38-partV-chap73-subchapI-sec7301.pdf
20. US Department of Veterans Affairs. Policy memorandum no. 2, policy in association of veterans’ hospitals with medical schools. January 30, 1946.
21. Veterans Health Care Expansion Act of 1973, Public Law 93-82. August 2, 1973. Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/STATUTE-87/pdf/STATUTE-87-Pg179.pdf
22. Residencies and internships, 38 USC § 7406 (2022). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/USCODE-2022-title38/pdf/USCODE-2022-title38-partV-chap74-subchapI-sec7406.pdf
23. Direct graduate medical education (DGME). Centers for Medicaid and Medicare Services. Updated December 5, 2023. Accessed March 1, 2024. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/DGME
24. Drezdzon MK, Cowley NJ, Sweeney DP, et al. Going for broke: the impact of cost of living on surgery resident stipend value. Ann Surg. 2023;278(6):1053-1059. doi:10.1097/SLA.0000000000005923
25. Special treatment: hospitals that incur indirect costs for graduate medical education programs, 42 CFR § 412.105 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec412-105.pdf
26. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1400.05, Disbursement agreements for health professions trainees appointed under 38 U.S.C. § 7406. June 2, 2021. Accessed March 1, 2024. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9293
27. Harada ND, Sanders KM, Bowman MA. Health systems education leadership: learning from the VA designated education officer role. Fed Pract. 2022;39(6):266-273. doi:10.12788/fp.0278
28. Schleiter Hitchell K, Johnson L. CMS finalizes rules for distribution of 1000 new Medicare-funded residency positions and changes to rural training track programs. J Grad Med Educ. 2022;14(2):245-249. doi:10.4300/JGME-D-22-00193.1
29. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1400.10, Educational cost contracts for health professions education. September 25, 2023. Accessed March 1, 2024. https://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=11480
30. Direct GME payments: general requirements, 42 CFR § 413.75 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec413-75.pdf
31. Direct GME payments: determination of the total number of FTE residents, 42 CFR § 413.78 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec413-78.pdf
32. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare financial management manual, chapter 8. Contractor procedures for provider audits. Accessed March 1, 2024. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/fin106c08.pdf
33. US Department of Health and Human Services, Office of Inspector General. CMS did not always ensure hospitals complied with Medicare reimbursement requirements for graduate medical education. OIG report A-02-17-01017. November 2018. Accessed March 1, 2024. https://oig.hhs.gov/oas/reports/region2/21701017.pdf
34. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Interns and Residents Information System (IRIS) XML format. Publication 100-20. Transmittal 11418. Change request 12724. May 19, 2022. Accessed March 1, 2024. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R11418OTN.pdf
35. Birnbaum AD, Byrne J, on behalf of the VA Office of Academic Affiliations. VHA Updates: Disbursement Policy and Education Cost Contracts. Presented at: American Association of Medical Colleges Webinar; June 2021. Accessed March 1, 2024. https://vimeo.com/644415670
36. Byrne JM, on behalf of the VA Office of Academic Affiliations. Disbursement procedures update for AY 23-24. Accessed March 1, 2024. https://www.va.gov/oaa/Videos/AffiliatePresentationDisbursementandEARsAY23-24.pptx
The US Department of Veterans Affairs (VA) has partnered with academic medical centers and programs since 1946 to provide clinical training for physician residents. Ranking second in federal graduate medical education (GME) funding to the Centers for Medicare and Medicaid Services (CMS), the $850 million VA GME budget annually reimburses > 250 GME-sponsoring institutions (affiliates) of 8000 GME programs for the clinical training of 49,000 individual residents rotating through > 11,000 full-time equivalent (FTE) positions.1 The VA also distributes $1.6 billion to VA facilities to offset the costs of conducting health professions education (HPE) (eg, facility infrastructure, salary support for VA instructors and preceptors, education office administration, and instructional equipment).2 The VA financial and educational contributions account for payment of 11% of resident positions nationally and allow academic medical centers to be less reliant on CMS GME funding.3,4 The VA contributions also provide opportunities for GME expansion,1,5,6 educational innovations,5,7 interprofessional and team-based care,8,9 and quality and safety training.10,11 The Table provides a comparison of CMS and VA GME reimbursability based on activity.
GME financing is complex, particularly the formulaic approach used by CMS, the details of which are often obscured in federal regulations. Due to this complexity and the $16 billion CMS GME budget, academic publications have focused on CMS GME financing while not fully explaining the VA GME policies and processes.4,12-14 By comparison, the VA GME financing model is relatively straightforward and governed by different statues and VA regulations, yet sharing some of the same principles as CMS regulations. Given the challenges in CMS reimbursement to fully support the cost of resident education, as well as the educational opportunities at the VA, the VA designs its reimbursement model to assure that affiliates receive appropriate payments.4,12,15 To ensure the continued success of VA GME partnerships, knowledge of VA GME financing has become increasingly important for designated institutional officers (DIOs) and residency program directors, particularly in light of recent investigations into oversight of the VA’s reimbursement to academic affiliates.
VA AUTHORITY
While the VA’s primary mission is “to provide a complete hospital medical service for the medical care and treatment of veterans,”early VA leaders recognized the importance of affiliating with the nation’s academic institutions.19 In 1946, the VA Policy Memorandum Number 2 established a partnership between the VA and the academic medical community.20 Additional legislation authorized specific agreements with academic affiliates for the central administration of salary and benefits for residents rotating at VA facilities. This process, known as disbursement, is an alternative payroll mechanism whereby the VA reimburses the academic affiliate for resident salary and benefits and the affiliate acts as the disbursing agent, issuing paychecks to residents.21,22
Resident FUNDING
By policy, with rare exceptions, the VA does not sponsor residency programs due to the challenges of providing an appropriate patient mix of age, sex, and medical conditions to meet accreditation standards.4 Nearly all VA reimbursements are for residents in affiliate-sponsored programs, while just 1% pays for residents in legacy, VA-sponsored residency programs at 2 VA facilities. The VA budget for resident (including fellows) salary and benefits is managed by the VA Office of Academic Affiliations (OAA), the national VA office responsible for oversight, policy, and funding of VA HPE programs.
Resident Salaries and Benefits
VA funding of resident salary and benefits are analogous with CMS direct GME (DGME), which is designed to cover resident salary and benefits costs.4,14,23 CMS DGME payments depend on a hospital’s volume of CMS inpatients and are based on a statutory formula, which uses the hospital’s resident FTE positions, the per-resident amount, and Medicare’s share of inpatient beds (Medicare patient load) to determine payments.12 The per-resident amount is set by statute, varies geographically, and is calculated by dividing the hospital’s allowable costs of GME (percentage of CMS inpatient days) divided by the number of residents.12,24
By comparison, the VA GME payment reimburses for each FTE based on the salary and benefits rate set by the academic affiliate. Reimbursement is calculated based on resident time spent at the VA multiplied by a daily salary rate. The daily salary rate is determined by dividing the resident’s total compensation (salary and benefits) by the number of calendar days in an academic year. Resident time spent at the VA facility is determined by obtaining rotation schedules provided by the academic affiliate and verifying resident clinical and educational activity during scheduled rotations.
Indirect Medical Education Funding
In addition to resident salary and benefits, funds to offset the cost of conducting HPE are provided to VA facilities. These funds are intended to improve and maintain necessary infrastructure for all HPE programs not just GME, including education office administration needs, teaching costs (ie, a portion of VA preceptors salary), and instructional equipment.
The Veterans Equitable Resource Allocation (VERA) is a national budgeting process for VA medical facilities that funds facility operational needs such as staff salary and benefits, infrastructure, and equipment.2 The education portion of the VERA, the VERA Education Support Component (VESC), is not managed by the OAA, but rather is distributed through the VERA model to the general budget of VA facilities hosting HPE (Figure). VESC funding in the VA budget is based on labor mapping of physician time spent in education; other labor mapping categories include clinical care, research, and administration. VA facility VESC funding is calculated based on the number of paid health profession trainees (HPTs) from all professions, apportioned according to the number of FTEs for physician residents and VA-paid HPTs in other disciplines. In fiscal year 2024, VA facilities received $115,812 for each physician resident FTE position and $84,906 for each VA-paid, non-GME FTE position.
The VESC is like CMS's indirect GME funding, termed Indirect Medical Education (IME), an additional payment for each Medicare patient discharged reflecting teaching hospitals’ higher patient care costs relative to nonteaching hospitals. Described elsewhere, IME is calculated using a resident-to-bed ratio and a multiplier, which is set by statute.4,25 While IME can be used for reimbursement for some resident clinical and educational activities(eg, research), VA VESC funds cannot be used for such activities and are part of the general facility budget and appropriated per the discretion of the medical facility director.
ESTABLISHING GME PARTNERSHIPS
An affiliation agreement establishes the administrative and legal requirements for educational relationships with academic affiliates and includes standards for conducting HPE, responsibilities for accreditation standards, program leadership, faculty, resources, supervision, academic policies, and procedures. The VA uses standardized affiliation agreement templates that have been vetted with accrediting bodies and the VA Office of General Counsel.
A disbursement agreement authorizes the VA to reimburse affiliates for resident salary and benefits for VA clinical and educational activities. The disbursement agreement details the fiscal arrangements (eg, payment in advance vs arrears, salary, and benefit rates, leave) for the reimbursement payments. Veterans Health Administration (VHA) Directive 1400.05 provides the policy and procedures for calculating reimbursement for HPT educational activities.26
The VA facility designated education officer (DEO) oversees all HPE programs and coordinates the affiliation and disbursement agreement processes.27 The DEO, affiliate DIO, residency program director, and VA residency site director determine the physician resident FTE positions assigned to a VA facility based on educational objectives and availability of educational resources at the VA facility, such as patient care opportunities, faculty supervisors, space, and equipment. The VA facility requests for resident FTE positions are submitted to the OAA by the facility DEO.
Once GME FTE positions are approved by the OAA, VA facilities work with their academic affiliate to submit the physician resident salary and benefit rate. Affiliate DIOs attest to the accuracy of the salary rate schedule and the local DEO submits the budget request to the OAA. Upon approval, the funds are transferred to the VA facility each fiscal year, which begins October 1. DEOs report quarterly to the OAA both budget needs and excesses based on variations in the approved FTEs due to additional VA rotations, physician resident attrition, or reassignment.
Resident Position Allocation
VA GME financing provides flexibility through periodic needs assessments and expansion initiatives. In August and December, DEOs collaborate with an academic affiliate to submit reports to the OAA confirming their projected GME needs for the next academic year. Additional positions requests are reviewed by the OAA; funding depends on budget and the educational justification. The OAA periodically issues GME expansion requests for proposal, which typically arise from legislation to address specific VA workforce needs. The VA facility DEO and affiliate GME leaders collaborate to apply for additional positions. For example, a VA GME expansion under the Veterans Access, Choice, and Accountability Act of 2014 added 1500 GME positions in 8 years for critically needed specialties and in rural and underserved areas.5 The Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act of 2018 authorized a pilot program for VA to fund residents at non-VA facilities with priority for Indian Health Services, Tribes and Tribal Organizations, Federally Qualified Health Centers, and US Department of Defense facilities to provide access to veterans in underserved areas.6
The VA GME financing system has flexibility to meet local needs for additional resident positions and to address broader VA workforce gaps through targeted expansion. Generally, CMS does not fund positions to address workforce needs, place residents in specific geographic areas, or require the training of certain types of residents.4 However, the Consolidated Appropriations Act of 2021 has provided the opportunity to address rural workforce needs.28
Reimbursement
The VA provides reimbursement for clinical and educational activities performed in VA facilities for the benefit of veterans as well as research, didactics, meetings and conferences, annual and sick leave, and orientation. The VA also may provide reimbursement for educational activities that occur off VA grounds (eg, the VA proportional share of a residency program’s didactic sessions). The VA does not reimburse for affiliate clinical duties or administrative costs, although a national policy allows VA facilities to reimburse affiliates for some GME overhead costs.29
CMS similarly reimburses for residency training time spent in patient care activities as well as orientation activities, didactics, leave, and, in some cases, research.4,30,31 CMS makes payments to hospitals, which may include sponsoring institutions and Medicare-eligible participating training sites.4,30,31 For both the VA and CMS, residents may not be counted twice for reimbursement by 2 federal agencies; in other words, a resident may not count for > 1 FTE.4,30-32
GME Oversight
VA GME funding came under significant scrutiny. At a 2016 House Veterans Affairs Committee hearing, Representative Phil Roe, MD (R-Tennessee), noted that no process existed at many VA facilities for “determining trainee presence” and that many VA medical centers had “difficulty tracking resident rotations”16 A VA Office of the Inspector General investigation recommended that the VA implement policies and procedures to improve oversight to “ensure residents are fully participating in educational activities” and that the VA is “paying the correct amount” to the affiliate.17 A 2020 General Accountability Office report outlined unclear policy guidance, incomplete tracking of resident activities, and improper fiscal processes for reimbursement and reconciliation of affiliate invoices.18
In response, the OAA created an oversight and compliance unit, revised VHA Directive 1400.05 (the policy for disbursement), and improved resident tracking procedures.26 The standard operating procedure that accompanied VHA Directive 1400.05 provides detailed information for the DEO and VA facility staff for tracking resident clinical and educational activities. FTE counts are essential to both VA and CMS for accurate reimbursement. The eAppendix and the Table provide a guide to reimbursable activities in the VA for the calculation of reimbursement, with a comparison to CMS.33,34 The OAA in cooperation with other VA staff and officers periodically conducts audits to assess compliance with disbursement policy and affiliate reimbursement accuracy.
In the VA, resident activities are captured on the VA Educational Activity Record, a standardized spreadsheet to track activities and calculate reimbursement. Each VA facility hosting resident physicians manually records resident activity by the half-day. This process is labor intensive, involving both VA and affiliate staff to accurately reconcile payments. To address the workload demands, the OAA is developing an online tool that will automate aspects of the tracking process. Also, to ensure adequate staffing, the OAA is in the process of implementing an office optimization project, providing standardized position descriptions, an organizational chart, and staffing levels for DEO offices in VA facilities.
Conclusions
This report describes the key policies and principles of VA GME financing, highlighting the essential similarities and differences between VA and CMS. Neither the VA nor CMS regulations allow for reimbursement for > 1 FTE position per resident, a principle that underpins the assignment of resident rotations and federal funding for GME and are similar with respect to reimbursement for patient care activities, didactics, research, orientation, and scholarly activity. While reimbursable activities in the VA require physical presence and care of veteran patients, CMS also limits reimbursement to resident activities in the hospital and approved other settings if the hospital is paying for resident salary and benefits in these settings. The VA provides some flexibility for offsite activities including didactics and, in specific circumstances, remote care of veteran patients (eg, teleradiology).
The VA and CMS use different GME financing models. For example, the CMS calculations for resident FTEs are complex, whereas VA calculations reimburse the salary and benefits as set by the academic affiliate. The VA process accounts for local variation in salary rates, whereas the per-resident amount set by CMS varies regionally and does not fully account for differences in the cost of living.24 Because all patients in VA facilities are veterans, VA calculations for reimbursement do not involve ratios of beds like the CMS calculations to determine a proportional share of reimbursement. The VA GME expansion tends to be more directed to VA health workforce needs than CMS, specifying the types of programs and geographic locations to address these needs.
The VA regularly reevaluates how affiliates are reimbursed for VA resident activity, balancing compliance with VA policies and the workload for VA and its affiliates. The VA obtains input from key stakeholders including DEOs, DIOs, and professional organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.35,36
Looking ahead, the VA is developing an online tool to improve the accuracy of affiliate reimbursement. The VA will also implement a standardized staffing model, organizational structure, and position descriptions for DEO offices. These initiatives will help reduce the burden of tracking and verifying resident activity and continue to support the 77-year partnership between VA and its affiliated institutions.
The US Department of Veterans Affairs (VA) has partnered with academic medical centers and programs since 1946 to provide clinical training for physician residents. Ranking second in federal graduate medical education (GME) funding to the Centers for Medicare and Medicaid Services (CMS), the $850 million VA GME budget annually reimburses > 250 GME-sponsoring institutions (affiliates) of 8000 GME programs for the clinical training of 49,000 individual residents rotating through > 11,000 full-time equivalent (FTE) positions.1 The VA also distributes $1.6 billion to VA facilities to offset the costs of conducting health professions education (HPE) (eg, facility infrastructure, salary support for VA instructors and preceptors, education office administration, and instructional equipment).2 The VA financial and educational contributions account for payment of 11% of resident positions nationally and allow academic medical centers to be less reliant on CMS GME funding.3,4 The VA contributions also provide opportunities for GME expansion,1,5,6 educational innovations,5,7 interprofessional and team-based care,8,9 and quality and safety training.10,11 The Table provides a comparison of CMS and VA GME reimbursability based on activity.
GME financing is complex, particularly the formulaic approach used by CMS, the details of which are often obscured in federal regulations. Due to this complexity and the $16 billion CMS GME budget, academic publications have focused on CMS GME financing while not fully explaining the VA GME policies and processes.4,12-14 By comparison, the VA GME financing model is relatively straightforward and governed by different statues and VA regulations, yet sharing some of the same principles as CMS regulations. Given the challenges in CMS reimbursement to fully support the cost of resident education, as well as the educational opportunities at the VA, the VA designs its reimbursement model to assure that affiliates receive appropriate payments.4,12,15 To ensure the continued success of VA GME partnerships, knowledge of VA GME financing has become increasingly important for designated institutional officers (DIOs) and residency program directors, particularly in light of recent investigations into oversight of the VA’s reimbursement to academic affiliates.
VA AUTHORITY
While the VA’s primary mission is “to provide a complete hospital medical service for the medical care and treatment of veterans,”early VA leaders recognized the importance of affiliating with the nation’s academic institutions.19 In 1946, the VA Policy Memorandum Number 2 established a partnership between the VA and the academic medical community.20 Additional legislation authorized specific agreements with academic affiliates for the central administration of salary and benefits for residents rotating at VA facilities. This process, known as disbursement, is an alternative payroll mechanism whereby the VA reimburses the academic affiliate for resident salary and benefits and the affiliate acts as the disbursing agent, issuing paychecks to residents.21,22
Resident FUNDING
By policy, with rare exceptions, the VA does not sponsor residency programs due to the challenges of providing an appropriate patient mix of age, sex, and medical conditions to meet accreditation standards.4 Nearly all VA reimbursements are for residents in affiliate-sponsored programs, while just 1% pays for residents in legacy, VA-sponsored residency programs at 2 VA facilities. The VA budget for resident (including fellows) salary and benefits is managed by the VA Office of Academic Affiliations (OAA), the national VA office responsible for oversight, policy, and funding of VA HPE programs.
Resident Salaries and Benefits
VA funding of resident salary and benefits are analogous with CMS direct GME (DGME), which is designed to cover resident salary and benefits costs.4,14,23 CMS DGME payments depend on a hospital’s volume of CMS inpatients and are based on a statutory formula, which uses the hospital’s resident FTE positions, the per-resident amount, and Medicare’s share of inpatient beds (Medicare patient load) to determine payments.12 The per-resident amount is set by statute, varies geographically, and is calculated by dividing the hospital’s allowable costs of GME (percentage of CMS inpatient days) divided by the number of residents.12,24
By comparison, the VA GME payment reimburses for each FTE based on the salary and benefits rate set by the academic affiliate. Reimbursement is calculated based on resident time spent at the VA multiplied by a daily salary rate. The daily salary rate is determined by dividing the resident’s total compensation (salary and benefits) by the number of calendar days in an academic year. Resident time spent at the VA facility is determined by obtaining rotation schedules provided by the academic affiliate and verifying resident clinical and educational activity during scheduled rotations.
Indirect Medical Education Funding
In addition to resident salary and benefits, funds to offset the cost of conducting HPE are provided to VA facilities. These funds are intended to improve and maintain necessary infrastructure for all HPE programs not just GME, including education office administration needs, teaching costs (ie, a portion of VA preceptors salary), and instructional equipment.
The Veterans Equitable Resource Allocation (VERA) is a national budgeting process for VA medical facilities that funds facility operational needs such as staff salary and benefits, infrastructure, and equipment.2 The education portion of the VERA, the VERA Education Support Component (VESC), is not managed by the OAA, but rather is distributed through the VERA model to the general budget of VA facilities hosting HPE (Figure). VESC funding in the VA budget is based on labor mapping of physician time spent in education; other labor mapping categories include clinical care, research, and administration. VA facility VESC funding is calculated based on the number of paid health profession trainees (HPTs) from all professions, apportioned according to the number of FTEs for physician residents and VA-paid HPTs in other disciplines. In fiscal year 2024, VA facilities received $115,812 for each physician resident FTE position and $84,906 for each VA-paid, non-GME FTE position.
The VESC is like CMS's indirect GME funding, termed Indirect Medical Education (IME), an additional payment for each Medicare patient discharged reflecting teaching hospitals’ higher patient care costs relative to nonteaching hospitals. Described elsewhere, IME is calculated using a resident-to-bed ratio and a multiplier, which is set by statute.4,25 While IME can be used for reimbursement for some resident clinical and educational activities(eg, research), VA VESC funds cannot be used for such activities and are part of the general facility budget and appropriated per the discretion of the medical facility director.
ESTABLISHING GME PARTNERSHIPS
An affiliation agreement establishes the administrative and legal requirements for educational relationships with academic affiliates and includes standards for conducting HPE, responsibilities for accreditation standards, program leadership, faculty, resources, supervision, academic policies, and procedures. The VA uses standardized affiliation agreement templates that have been vetted with accrediting bodies and the VA Office of General Counsel.
A disbursement agreement authorizes the VA to reimburse affiliates for resident salary and benefits for VA clinical and educational activities. The disbursement agreement details the fiscal arrangements (eg, payment in advance vs arrears, salary, and benefit rates, leave) for the reimbursement payments. Veterans Health Administration (VHA) Directive 1400.05 provides the policy and procedures for calculating reimbursement for HPT educational activities.26
The VA facility designated education officer (DEO) oversees all HPE programs and coordinates the affiliation and disbursement agreement processes.27 The DEO, affiliate DIO, residency program director, and VA residency site director determine the physician resident FTE positions assigned to a VA facility based on educational objectives and availability of educational resources at the VA facility, such as patient care opportunities, faculty supervisors, space, and equipment. The VA facility requests for resident FTE positions are submitted to the OAA by the facility DEO.
Once GME FTE positions are approved by the OAA, VA facilities work with their academic affiliate to submit the physician resident salary and benefit rate. Affiliate DIOs attest to the accuracy of the salary rate schedule and the local DEO submits the budget request to the OAA. Upon approval, the funds are transferred to the VA facility each fiscal year, which begins October 1. DEOs report quarterly to the OAA both budget needs and excesses based on variations in the approved FTEs due to additional VA rotations, physician resident attrition, or reassignment.
Resident Position Allocation
VA GME financing provides flexibility through periodic needs assessments and expansion initiatives. In August and December, DEOs collaborate with an academic affiliate to submit reports to the OAA confirming their projected GME needs for the next academic year. Additional positions requests are reviewed by the OAA; funding depends on budget and the educational justification. The OAA periodically issues GME expansion requests for proposal, which typically arise from legislation to address specific VA workforce needs. The VA facility DEO and affiliate GME leaders collaborate to apply for additional positions. For example, a VA GME expansion under the Veterans Access, Choice, and Accountability Act of 2014 added 1500 GME positions in 8 years for critically needed specialties and in rural and underserved areas.5 The Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act of 2018 authorized a pilot program for VA to fund residents at non-VA facilities with priority for Indian Health Services, Tribes and Tribal Organizations, Federally Qualified Health Centers, and US Department of Defense facilities to provide access to veterans in underserved areas.6
The VA GME financing system has flexibility to meet local needs for additional resident positions and to address broader VA workforce gaps through targeted expansion. Generally, CMS does not fund positions to address workforce needs, place residents in specific geographic areas, or require the training of certain types of residents.4 However, the Consolidated Appropriations Act of 2021 has provided the opportunity to address rural workforce needs.28
Reimbursement
The VA provides reimbursement for clinical and educational activities performed in VA facilities for the benefit of veterans as well as research, didactics, meetings and conferences, annual and sick leave, and orientation. The VA also may provide reimbursement for educational activities that occur off VA grounds (eg, the VA proportional share of a residency program’s didactic sessions). The VA does not reimburse for affiliate clinical duties or administrative costs, although a national policy allows VA facilities to reimburse affiliates for some GME overhead costs.29
CMS similarly reimburses for residency training time spent in patient care activities as well as orientation activities, didactics, leave, and, in some cases, research.4,30,31 CMS makes payments to hospitals, which may include sponsoring institutions and Medicare-eligible participating training sites.4,30,31 For both the VA and CMS, residents may not be counted twice for reimbursement by 2 federal agencies; in other words, a resident may not count for > 1 FTE.4,30-32
GME Oversight
VA GME funding came under significant scrutiny. At a 2016 House Veterans Affairs Committee hearing, Representative Phil Roe, MD (R-Tennessee), noted that no process existed at many VA facilities for “determining trainee presence” and that many VA medical centers had “difficulty tracking resident rotations”16 A VA Office of the Inspector General investigation recommended that the VA implement policies and procedures to improve oversight to “ensure residents are fully participating in educational activities” and that the VA is “paying the correct amount” to the affiliate.17 A 2020 General Accountability Office report outlined unclear policy guidance, incomplete tracking of resident activities, and improper fiscal processes for reimbursement and reconciliation of affiliate invoices.18
In response, the OAA created an oversight and compliance unit, revised VHA Directive 1400.05 (the policy for disbursement), and improved resident tracking procedures.26 The standard operating procedure that accompanied VHA Directive 1400.05 provides detailed information for the DEO and VA facility staff for tracking resident clinical and educational activities. FTE counts are essential to both VA and CMS for accurate reimbursement. The eAppendix and the Table provide a guide to reimbursable activities in the VA for the calculation of reimbursement, with a comparison to CMS.33,34 The OAA in cooperation with other VA staff and officers periodically conducts audits to assess compliance with disbursement policy and affiliate reimbursement accuracy.
In the VA, resident activities are captured on the VA Educational Activity Record, a standardized spreadsheet to track activities and calculate reimbursement. Each VA facility hosting resident physicians manually records resident activity by the half-day. This process is labor intensive, involving both VA and affiliate staff to accurately reconcile payments. To address the workload demands, the OAA is developing an online tool that will automate aspects of the tracking process. Also, to ensure adequate staffing, the OAA is in the process of implementing an office optimization project, providing standardized position descriptions, an organizational chart, and staffing levels for DEO offices in VA facilities.
Conclusions
This report describes the key policies and principles of VA GME financing, highlighting the essential similarities and differences between VA and CMS. Neither the VA nor CMS regulations allow for reimbursement for > 1 FTE position per resident, a principle that underpins the assignment of resident rotations and federal funding for GME and are similar with respect to reimbursement for patient care activities, didactics, research, orientation, and scholarly activity. While reimbursable activities in the VA require physical presence and care of veteran patients, CMS also limits reimbursement to resident activities in the hospital and approved other settings if the hospital is paying for resident salary and benefits in these settings. The VA provides some flexibility for offsite activities including didactics and, in specific circumstances, remote care of veteran patients (eg, teleradiology).
The VA and CMS use different GME financing models. For example, the CMS calculations for resident FTEs are complex, whereas VA calculations reimburse the salary and benefits as set by the academic affiliate. The VA process accounts for local variation in salary rates, whereas the per-resident amount set by CMS varies regionally and does not fully account for differences in the cost of living.24 Because all patients in VA facilities are veterans, VA calculations for reimbursement do not involve ratios of beds like the CMS calculations to determine a proportional share of reimbursement. The VA GME expansion tends to be more directed to VA health workforce needs than CMS, specifying the types of programs and geographic locations to address these needs.
The VA regularly reevaluates how affiliates are reimbursed for VA resident activity, balancing compliance with VA policies and the workload for VA and its affiliates. The VA obtains input from key stakeholders including DEOs, DIOs, and professional organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education.35,36
Looking ahead, the VA is developing an online tool to improve the accuracy of affiliate reimbursement. The VA will also implement a standardized staffing model, organizational structure, and position descriptions for DEO offices. These initiatives will help reduce the burden of tracking and verifying resident activity and continue to support the 77-year partnership between VA and its affiliated institutions.
1. Klink KA, Albanese AP, Bope ET, Sanders KM. Veterans Affairs graduate medical education expansion addresses US physician workforce needs. Acad Med. 2022;97(8):1144-1150. doi:10.1097/ACM.0000000000004545
2. Andrus CH, Johnson K, Pierce E, Romito PJ, Hartel P, Berrios‐Guccione S, Best W. Finance modeling in the delivery of medical care in tertiary‐care hospitals in the Department of Veterans Affairs. J Surg Res. 2001;96(2):152-157. doi:10.1006/jsre.1999.5728
3. Petrakis IL, Kozal M. Academic medical centers and the U.S. Department of Veterans Affairs: a 75-year partnership influences medical education, scientific discovery, and clinical care. Acad Med. 2022;97(8):1110-1113. doi:10.1097/ACM.0000000000004734
4. Heisler EJ, Mendez BH, Mitchell A, Panangala SV, Villagrana MA. Federal support for graduate medical education: an overview (R44376). Congressional Research Service report R44376; version 11. Updated December 27, 2018. Accessed March 2, 2024. https://crsreports.congress.gov/product/pdf/R/R44376/11
5. Chang BK, Brannen JL. The Veterans Access, Choice, and Accountability Act of 2014: examining graduate medical education enhancement in the Department of Veterans Affairs. Acad Med. 2015;90(9):1196-1198. doi:10.1097/ACM.0000000000000795
6. Albanese AP, Bope ET, Sanders KM, Bowman M. The VA MISSION Act of 2018: a potential game changer for rural GME expansion and veteran health care. J Rural Health. 2020;36(1):133-136. doi:10.1111/jrh.12360
7. Lypson ML, Roberts LW. Valuing the partnership between the Veterans Health Administration and academic medicine. Acad Med. 2022;97(8):1091-1093. doi:10.1097/ACM.0000000000004748
8. Harada ND, Traylor L, Rugen KW, et al. Interprofessional transformation of clinical education: the first six years of the Veterans Affairs Centers of Excellence in Primary Care Education. J Interprof Care. 2023;37(suppl 1):S86-S94. doi:10.1080/13561820.2018.1433642
9. Harada ND, Rajashekara S, Sansgiry S, et al. Developing interprofessional primary care teams: alumni evaluation of the Department of Veterans Affairs Centers of Excellence in Primary Care Education Program. J Med Educ Curric Dev. 2019;6:2382120519875455. doi:10.1177/2382120519875455
10. Splaine ME, Ogrinc G, Gilman SC, et al. The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars. Acad Med. 2009;84(12):1741-1748. doi:10.1097/ACM.0b013e3181bfdcef
11. Watts BV, Paull DE, Williams LC, Neily J, Hemphill RR, Brannen JL. Department of Veterans Affairs chief resident in quality and patient safety program: a model to spread change. Am J Med Qual. 2016;31(6):598-600. doi:10.1177/1062860616643403
12. He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: a narrative review. Am J Surg. 2021;221(1):65-71. doi:10.1016/j.amjsurg.2020.06.007
13. Villagrana M. Medicare graduate medical education payments: an overview. Congressional Research Service report IF10960. Updated September 29, 2022. Accessed March 2, 2024. https://crsreports.congress.gov/product/pdf/IF/IF10960
14. Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Eden J, Berwick DM, Wilensky GR, eds. Washington, DC: National Academies Press; 2014. doi:10.17226/18754
15. Physician workforce: caps on Medicare-funded graduate medical education at teaching hospitals. Report to congressional requesters. GAO-21-391. May 21, 2021. Accessed March 1, 2024. https://www.gao.gov/assets/gao-21-391.pdf
16. VA and Academic Affiliates: Who Benefits? Hearing Before the Subcommittee on Oversight and Investigations of the Committee on Veterans’ Affairs, 114th Cong, 2nd Sess (2016). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CHRG-115hhrg29685/html/CHRG-115hhrg29685.htm
17. US Department of Veterans Affairs, Office of Inspector General (OIG). Veterans Health Administration. Review of resident and part-time physician time and attendance at the Oklahoma City VA Health Care System. OIG report 17-00253-93. March 28, 2018. Accessed March 1, 2024. https://www.oversight.gov/sites/default/files/oig-reports/VAOIG-17-00253-93.pdf
18. VA health care: actions needed to improve oversight of graduate medical education reimbursement. Report to the ranking member, Committee on Veterans’ Affairs, House of Representatives. GAO-20-553. July 2020. Accessed March 1, 2024. https://www.gao.gov/assets/710/708275.pdf
19. Functions of Veterans Health Administration: in general, 38 USC §7301 (2022). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/USCODE-2022-title38/pdf/USCODE-2022-title38-partV-chap73-subchapI-sec7301.pdf
20. US Department of Veterans Affairs. Policy memorandum no. 2, policy in association of veterans’ hospitals with medical schools. January 30, 1946.
21. Veterans Health Care Expansion Act of 1973, Public Law 93-82. August 2, 1973. Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/STATUTE-87/pdf/STATUTE-87-Pg179.pdf
22. Residencies and internships, 38 USC § 7406 (2022). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/USCODE-2022-title38/pdf/USCODE-2022-title38-partV-chap74-subchapI-sec7406.pdf
23. Direct graduate medical education (DGME). Centers for Medicaid and Medicare Services. Updated December 5, 2023. Accessed March 1, 2024. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/DGME
24. Drezdzon MK, Cowley NJ, Sweeney DP, et al. Going for broke: the impact of cost of living on surgery resident stipend value. Ann Surg. 2023;278(6):1053-1059. doi:10.1097/SLA.0000000000005923
25. Special treatment: hospitals that incur indirect costs for graduate medical education programs, 42 CFR § 412.105 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec412-105.pdf
26. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1400.05, Disbursement agreements for health professions trainees appointed under 38 U.S.C. § 7406. June 2, 2021. Accessed March 1, 2024. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9293
27. Harada ND, Sanders KM, Bowman MA. Health systems education leadership: learning from the VA designated education officer role. Fed Pract. 2022;39(6):266-273. doi:10.12788/fp.0278
28. Schleiter Hitchell K, Johnson L. CMS finalizes rules for distribution of 1000 new Medicare-funded residency positions and changes to rural training track programs. J Grad Med Educ. 2022;14(2):245-249. doi:10.4300/JGME-D-22-00193.1
29. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1400.10, Educational cost contracts for health professions education. September 25, 2023. Accessed March 1, 2024. https://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=11480
30. Direct GME payments: general requirements, 42 CFR § 413.75 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec413-75.pdf
31. Direct GME payments: determination of the total number of FTE residents, 42 CFR § 413.78 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec413-78.pdf
32. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare financial management manual, chapter 8. Contractor procedures for provider audits. Accessed March 1, 2024. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/fin106c08.pdf
33. US Department of Health and Human Services, Office of Inspector General. CMS did not always ensure hospitals complied with Medicare reimbursement requirements for graduate medical education. OIG report A-02-17-01017. November 2018. Accessed March 1, 2024. https://oig.hhs.gov/oas/reports/region2/21701017.pdf
34. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Interns and Residents Information System (IRIS) XML format. Publication 100-20. Transmittal 11418. Change request 12724. May 19, 2022. Accessed March 1, 2024. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R11418OTN.pdf
35. Birnbaum AD, Byrne J, on behalf of the VA Office of Academic Affiliations. VHA Updates: Disbursement Policy and Education Cost Contracts. Presented at: American Association of Medical Colleges Webinar; June 2021. Accessed March 1, 2024. https://vimeo.com/644415670
36. Byrne JM, on behalf of the VA Office of Academic Affiliations. Disbursement procedures update for AY 23-24. Accessed March 1, 2024. https://www.va.gov/oaa/Videos/AffiliatePresentationDisbursementandEARsAY23-24.pptx
1. Klink KA, Albanese AP, Bope ET, Sanders KM. Veterans Affairs graduate medical education expansion addresses US physician workforce needs. Acad Med. 2022;97(8):1144-1150. doi:10.1097/ACM.0000000000004545
2. Andrus CH, Johnson K, Pierce E, Romito PJ, Hartel P, Berrios‐Guccione S, Best W. Finance modeling in the delivery of medical care in tertiary‐care hospitals in the Department of Veterans Affairs. J Surg Res. 2001;96(2):152-157. doi:10.1006/jsre.1999.5728
3. Petrakis IL, Kozal M. Academic medical centers and the U.S. Department of Veterans Affairs: a 75-year partnership influences medical education, scientific discovery, and clinical care. Acad Med. 2022;97(8):1110-1113. doi:10.1097/ACM.0000000000004734
4. Heisler EJ, Mendez BH, Mitchell A, Panangala SV, Villagrana MA. Federal support for graduate medical education: an overview (R44376). Congressional Research Service report R44376; version 11. Updated December 27, 2018. Accessed March 2, 2024. https://crsreports.congress.gov/product/pdf/R/R44376/11
5. Chang BK, Brannen JL. The Veterans Access, Choice, and Accountability Act of 2014: examining graduate medical education enhancement in the Department of Veterans Affairs. Acad Med. 2015;90(9):1196-1198. doi:10.1097/ACM.0000000000000795
6. Albanese AP, Bope ET, Sanders KM, Bowman M. The VA MISSION Act of 2018: a potential game changer for rural GME expansion and veteran health care. J Rural Health. 2020;36(1):133-136. doi:10.1111/jrh.12360
7. Lypson ML, Roberts LW. Valuing the partnership between the Veterans Health Administration and academic medicine. Acad Med. 2022;97(8):1091-1093. doi:10.1097/ACM.0000000000004748
8. Harada ND, Traylor L, Rugen KW, et al. Interprofessional transformation of clinical education: the first six years of the Veterans Affairs Centers of Excellence in Primary Care Education. J Interprof Care. 2023;37(suppl 1):S86-S94. doi:10.1080/13561820.2018.1433642
9. Harada ND, Rajashekara S, Sansgiry S, et al. Developing interprofessional primary care teams: alumni evaluation of the Department of Veterans Affairs Centers of Excellence in Primary Care Education Program. J Med Educ Curric Dev. 2019;6:2382120519875455. doi:10.1177/2382120519875455
10. Splaine ME, Ogrinc G, Gilman SC, et al. The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars. Acad Med. 2009;84(12):1741-1748. doi:10.1097/ACM.0b013e3181bfdcef
11. Watts BV, Paull DE, Williams LC, Neily J, Hemphill RR, Brannen JL. Department of Veterans Affairs chief resident in quality and patient safety program: a model to spread change. Am J Med Qual. 2016;31(6):598-600. doi:10.1177/1062860616643403
12. He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: a narrative review. Am J Surg. 2021;221(1):65-71. doi:10.1016/j.amjsurg.2020.06.007
13. Villagrana M. Medicare graduate medical education payments: an overview. Congressional Research Service report IF10960. Updated September 29, 2022. Accessed March 2, 2024. https://crsreports.congress.gov/product/pdf/IF/IF10960
14. Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Eden J, Berwick DM, Wilensky GR, eds. Washington, DC: National Academies Press; 2014. doi:10.17226/18754
15. Physician workforce: caps on Medicare-funded graduate medical education at teaching hospitals. Report to congressional requesters. GAO-21-391. May 21, 2021. Accessed March 1, 2024. https://www.gao.gov/assets/gao-21-391.pdf
16. VA and Academic Affiliates: Who Benefits? Hearing Before the Subcommittee on Oversight and Investigations of the Committee on Veterans’ Affairs, 114th Cong, 2nd Sess (2016). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CHRG-115hhrg29685/html/CHRG-115hhrg29685.htm
17. US Department of Veterans Affairs, Office of Inspector General (OIG). Veterans Health Administration. Review of resident and part-time physician time and attendance at the Oklahoma City VA Health Care System. OIG report 17-00253-93. March 28, 2018. Accessed March 1, 2024. https://www.oversight.gov/sites/default/files/oig-reports/VAOIG-17-00253-93.pdf
18. VA health care: actions needed to improve oversight of graduate medical education reimbursement. Report to the ranking member, Committee on Veterans’ Affairs, House of Representatives. GAO-20-553. July 2020. Accessed March 1, 2024. https://www.gao.gov/assets/710/708275.pdf
19. Functions of Veterans Health Administration: in general, 38 USC §7301 (2022). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/USCODE-2022-title38/pdf/USCODE-2022-title38-partV-chap73-subchapI-sec7301.pdf
20. US Department of Veterans Affairs. Policy memorandum no. 2, policy in association of veterans’ hospitals with medical schools. January 30, 1946.
21. Veterans Health Care Expansion Act of 1973, Public Law 93-82. August 2, 1973. Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/STATUTE-87/pdf/STATUTE-87-Pg179.pdf
22. Residencies and internships, 38 USC § 7406 (2022). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/USCODE-2022-title38/pdf/USCODE-2022-title38-partV-chap74-subchapI-sec7406.pdf
23. Direct graduate medical education (DGME). Centers for Medicaid and Medicare Services. Updated December 5, 2023. Accessed March 1, 2024. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/DGME
24. Drezdzon MK, Cowley NJ, Sweeney DP, et al. Going for broke: the impact of cost of living on surgery resident stipend value. Ann Surg. 2023;278(6):1053-1059. doi:10.1097/SLA.0000000000005923
25. Special treatment: hospitals that incur indirect costs for graduate medical education programs, 42 CFR § 412.105 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec412-105.pdf
26. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1400.05, Disbursement agreements for health professions trainees appointed under 38 U.S.C. § 7406. June 2, 2021. Accessed March 1, 2024. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9293
27. Harada ND, Sanders KM, Bowman MA. Health systems education leadership: learning from the VA designated education officer role. Fed Pract. 2022;39(6):266-273. doi:10.12788/fp.0278
28. Schleiter Hitchell K, Johnson L. CMS finalizes rules for distribution of 1000 new Medicare-funded residency positions and changes to rural training track programs. J Grad Med Educ. 2022;14(2):245-249. doi:10.4300/JGME-D-22-00193.1
29. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 1400.10, Educational cost contracts for health professions education. September 25, 2023. Accessed March 1, 2024. https://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=11480
30. Direct GME payments: general requirements, 42 CFR § 413.75 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec413-75.pdf
31. Direct GME payments: determination of the total number of FTE residents, 42 CFR § 413.78 (2023). Accessed March 1, 2024. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol2/pdf/CFR-2023-title42-vol2-sec413-78.pdf
32. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare financial management manual, chapter 8. Contractor procedures for provider audits. Accessed March 1, 2024. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/fin106c08.pdf
33. US Department of Health and Human Services, Office of Inspector General. CMS did not always ensure hospitals complied with Medicare reimbursement requirements for graduate medical education. OIG report A-02-17-01017. November 2018. Accessed March 1, 2024. https://oig.hhs.gov/oas/reports/region2/21701017.pdf
34. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Interns and Residents Information System (IRIS) XML format. Publication 100-20. Transmittal 11418. Change request 12724. May 19, 2022. Accessed March 1, 2024. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R11418OTN.pdf
35. Birnbaum AD, Byrne J, on behalf of the VA Office of Academic Affiliations. VHA Updates: Disbursement Policy and Education Cost Contracts. Presented at: American Association of Medical Colleges Webinar; June 2021. Accessed March 1, 2024. https://vimeo.com/644415670
36. Byrne JM, on behalf of the VA Office of Academic Affiliations. Disbursement procedures update for AY 23-24. Accessed March 1, 2024. https://www.va.gov/oaa/Videos/AffiliatePresentationDisbursementandEARsAY23-24.pptx
A First Look at the VA MISSION Act Veteran Health Administration Medical School Scholarship and Loan Repayment Programs
As one of 4 statutory missions, the US Department of Veterans Affairs (VA) educates and trains health professionals to enhance the quality of and timely access to care provided to veterans within the Veterans Health Administration (VHA). To achieve its mission to
Despite its long-term success affiliating with medical schools, VA has continued to be challenged by physician staff shortages with wide variability in the number and specialty of available health care professionals across facilities.3,4 A 2020 VA Office of Inspector General report on VHA occupational staffing shortages concluded that numerous physician specialties were difficult to recruit due to a lack of qualified applicants, noncompetitive salary, and less desirable geographic locations.3
Federal health professions scholarship programs and loan repayment programs have long been used to address physician shortages.4 Focusing on physician shortages in underserved areas in the US, the Emergency Health Personnel Act of 1970 and its subsequent amendments paved the way for various federal medical school scholarship and loan repayment programs.5 Similarly, physician shortages in the armed forces were mitigated through the Uniformed Services Health Professions Revitalization Act of 1972 (USHPRA).6,7
In 2018, Congress passed the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act, which included sections designed to alleviate physician shortages in the VHA.8 These sections authorized scholarships similar to those offered by the US Department of Defense (DoD) and loan repayment programs. Section 301 created the Health Professions Scholarship Program (HPSP), which offers scholarships for physicians and dentists. Section 302 increased the maximum debt reduction through the Education Debt Reduction Program (EDRP). Section 303 authorizes the Specialty Education Loan Repayment Program (SELRP), which provides for repayment of educational loans for physicians in specialties deemed necessary for VA. Finally, Section 304 created the Veterans Healing Veterans (VHV), a pilot scholarship specifically for veteran medical students.
Program Characteristics
Health Professions Scholarship
The VA HPSP is a program for physicians and dentists that extends from 2020 to 2033. The HPSP funds the costs of tuition, fees, and provides a stipend with a service obligation of 18 months for each year of support. The program is authorized for 10 years and must provide a minimum of 50 scholarships annually for physicians or dentists based on VHA needs. Applications are screened based on criteria that include a commitment to rural or underserved populations, veteran status, grade point average, essays, and letters of recommendation. Although the minimum required number of scholarships annually is 50, VA anticipates providing 1000 scholarships over 10 years with an aim to significantly increase the number physicians at VHA facilities (Table 1).
Implemented in 2020, the VHV was a 1-year pilot program. It offered scholarships to 2 veterans attending medical school at each of the 5 Teague-Cranston and the 4 Historically Black College and University (HBCU) medical schools (Table 2). The intent of the program was to determine the feasibility of increasing the pool of veteran physicians at VHA. Eligible applicants were notified of the scholarship opportunity through the American Medical College Application Service or through the medical school. Applicants must have separated from military service within the preceding 10 years of being admitted to medical school. In exchange for full tuition, fees, a monthly stipend, and rotation travel costs, the recipients accepted a 4-year clinical service obligation at VA facilities after completing their residency training.
Specialty Education Loan Repayment
The SELRP is a loan repayment program available to recently graduated physicians. Applicants must have graduated from an accredited medical or osteopathic school, matched to an accredited residency program and be ≥ 2 years from completion of residency. The specialties qualifying for SELRP are determined through an analysis of succession planning by the VA Office of Workforce Management and Consulting and change based on VA physician workforce needs. The SELRP provides loan repayment in the amount of $40,000 per year for up to 4 years, with a service obligation of 1 year for each $40,000 of support. In April 2021, VA began accepting applications from the eligible specialties of family medicine, internal medicine, gastroenterology, psychiatry, emergency medicine, and geriatrics.
Education Debt Reduction
The EDRP offers debt relief to clinicians in the most difficult to recruit professions, including physicians (generalists and specialists), registered nurses, licensed practical nurses, social workers, and psychologists. The list of difficult to recruit positions is developed annually by VA facilities. Annual reimbursements through the program may be used for tuition and expenses, such as fees, books, supplies, equipment, and other materials. In 2018, through the MISSION Act Section 302, the annual loan repayment was increased from $24,000 to $40,000, and the maximum level of support was increased from $120,000 to $200,000 over 5 years. Recipients receive reimbursement for loan repayment at the end of each year or service period and recipients are not required to remain in VA for 5 years.
Program Results
Health Professions Scholarship
For academic years 2020/2021 and 2021/2022, 126 HPSP applications from both allopathic and osteopathic schools were submitted and 51 scholarships were awarded (Table 3). Assuming an average residency length of 4 years, VHA estimates that these awards will yield 204 service-year equivalents by 2029.
Veterans Healing Veterans
In the VHV program, scholarship recipients came from 5 Teague-Cranston schools; 2 at University of South Carolina, 2 at East Tennessee State University, 2 at Wright State University, 1 at Texas A&M College of Medicine, 1 at Marshall University; and 3 HBCUs; 2 at Howard University, 1 at Morehouse School of Medicine and 1 at Meharry Medical College. The Charles R. Drew University of Medicine and Science did not nominate any students for the scholarship. Assuming all recipients complete postgraduate training, the VHV scholarship program will provide an additional 12 veteran physicians to serve at VA for at least 4 years each (48 service years).
Specialty Education Loan Repayment
Fourteen applicants have been approved, including 5 in psychiatry, 4 in family medicine, 3 in internal medicine, 1 in emergency medicine, and 1 in geriatrics. The mean loan repayment is anticipated to be $110,000 and equating to 38.5 VA service years or a mean of 2.3 years of service obligation per individual for the first cohort. The program has no termination date, and with continued funding, VA anticipates granting 100 loan repayments annually.
Education Debt Reduction
Since 2018, 1,546 VA physicians have received EDRP awards. Due to the increased reimbursement provided through the MISSION Act, average physician award amounts have increased from $96,090 in 2018 to $142,557 in 2019 and $148,302 in 2020.
Conclusions
The VA physician scholarship and loan repayment programs outlined in the MISSION Act build on the success of existing federal scholarship programs by providing opportunities for physician trainees to alleviate educational debt and explore a VA health professions career.
Looking ahead, VA must focus on measuring the success of the MISSION scholarship and loan repayment programs by tracking rates of acceptance and student graduation, residency and fellowship completion, and placement in VA medical facilities—both for the service obligation and future employment. Ultimately, the total impact on VA staffing, especially at rural and underresourced sites, will determine the success of the MISSION programs.
1. VA Policy Memorandum #2. Policy in Association of Veterans’ Hospitals with Medical Schools. US Department of Veterans Affairs. January 20, 1946. Accessed February 17, 2022. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf 2. Gilman SC, Chang BK, Zeiss RA, Dougherty MB, Marks WJ, Ludke DA, Cox M. “The academic mission of the Department of Veterans Affairs.” In: Praeger Handbook of Veterans’ Health: History, Challenges, Issues, and Developments. Praeger; 2012:53-82.
3. Office of Inspector General, Veterans Health Administration OIG Determination of VHA Occupational Staffing Shortages FY2020. US Department of Veterans Affairs. Published September 23, 2020. Accessed February 17, 2022. https://www.va.gov/oig/pubs/VAOIG-20-01249-259.pdf
4. Hussey PS, Ringel J, et al. Resources and capabilities of the Department of Veterans Affairs to provide timely and accessible care to veterans. Rand Health Q. 2015;5(4). Accessed February 17, 2022. https://www.rand.org/content/dam/rand/pubs/research_reports/RR1100/RR1165z2/RAND_RR1165z2.pdf
5. Lynch A, Best T, Gutierrez SC, Daily JA. What Should I Do With My Student Loans? A Proposed Strategy for Educational Debt Management. J Grad Med Educ. 2018;10(1):11-15. doi:10.4300/JGME-D-17-00279.1
6. The Uniformed Services Health Professions Revitalization Act of 1972, PL 92-426. US Government Publishing Office. Published 1972. Accessed February 17, 2022. https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg713.pdf
7. Armed Forces Health Professions Financial Assistance Programs, 10 USC § 105 (2006).
8. ‘‘VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018’’. H.R. 5674. 115th Congress; Report No. 115-671, Part 1. May 3, 2018. Accessed February 17, 2022. https://www.congress.gov/115/bills/hr5674/BILLS-115hr5674rh.pdf
As one of 4 statutory missions, the US Department of Veterans Affairs (VA) educates and trains health professionals to enhance the quality of and timely access to care provided to veterans within the Veterans Health Administration (VHA). To achieve its mission to
Despite its long-term success affiliating with medical schools, VA has continued to be challenged by physician staff shortages with wide variability in the number and specialty of available health care professionals across facilities.3,4 A 2020 VA Office of Inspector General report on VHA occupational staffing shortages concluded that numerous physician specialties were difficult to recruit due to a lack of qualified applicants, noncompetitive salary, and less desirable geographic locations.3
Federal health professions scholarship programs and loan repayment programs have long been used to address physician shortages.4 Focusing on physician shortages in underserved areas in the US, the Emergency Health Personnel Act of 1970 and its subsequent amendments paved the way for various federal medical school scholarship and loan repayment programs.5 Similarly, physician shortages in the armed forces were mitigated through the Uniformed Services Health Professions Revitalization Act of 1972 (USHPRA).6,7
In 2018, Congress passed the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act, which included sections designed to alleviate physician shortages in the VHA.8 These sections authorized scholarships similar to those offered by the US Department of Defense (DoD) and loan repayment programs. Section 301 created the Health Professions Scholarship Program (HPSP), which offers scholarships for physicians and dentists. Section 302 increased the maximum debt reduction through the Education Debt Reduction Program (EDRP). Section 303 authorizes the Specialty Education Loan Repayment Program (SELRP), which provides for repayment of educational loans for physicians in specialties deemed necessary for VA. Finally, Section 304 created the Veterans Healing Veterans (VHV), a pilot scholarship specifically for veteran medical students.
Program Characteristics
Health Professions Scholarship
The VA HPSP is a program for physicians and dentists that extends from 2020 to 2033. The HPSP funds the costs of tuition, fees, and provides a stipend with a service obligation of 18 months for each year of support. The program is authorized for 10 years and must provide a minimum of 50 scholarships annually for physicians or dentists based on VHA needs. Applications are screened based on criteria that include a commitment to rural or underserved populations, veteran status, grade point average, essays, and letters of recommendation. Although the minimum required number of scholarships annually is 50, VA anticipates providing 1000 scholarships over 10 years with an aim to significantly increase the number physicians at VHA facilities (Table 1).
Implemented in 2020, the VHV was a 1-year pilot program. It offered scholarships to 2 veterans attending medical school at each of the 5 Teague-Cranston and the 4 Historically Black College and University (HBCU) medical schools (Table 2). The intent of the program was to determine the feasibility of increasing the pool of veteran physicians at VHA. Eligible applicants were notified of the scholarship opportunity through the American Medical College Application Service or through the medical school. Applicants must have separated from military service within the preceding 10 years of being admitted to medical school. In exchange for full tuition, fees, a monthly stipend, and rotation travel costs, the recipients accepted a 4-year clinical service obligation at VA facilities after completing their residency training.
Specialty Education Loan Repayment
The SELRP is a loan repayment program available to recently graduated physicians. Applicants must have graduated from an accredited medical or osteopathic school, matched to an accredited residency program and be ≥ 2 years from completion of residency. The specialties qualifying for SELRP are determined through an analysis of succession planning by the VA Office of Workforce Management and Consulting and change based on VA physician workforce needs. The SELRP provides loan repayment in the amount of $40,000 per year for up to 4 years, with a service obligation of 1 year for each $40,000 of support. In April 2021, VA began accepting applications from the eligible specialties of family medicine, internal medicine, gastroenterology, psychiatry, emergency medicine, and geriatrics.
Education Debt Reduction
The EDRP offers debt relief to clinicians in the most difficult to recruit professions, including physicians (generalists and specialists), registered nurses, licensed practical nurses, social workers, and psychologists. The list of difficult to recruit positions is developed annually by VA facilities. Annual reimbursements through the program may be used for tuition and expenses, such as fees, books, supplies, equipment, and other materials. In 2018, through the MISSION Act Section 302, the annual loan repayment was increased from $24,000 to $40,000, and the maximum level of support was increased from $120,000 to $200,000 over 5 years. Recipients receive reimbursement for loan repayment at the end of each year or service period and recipients are not required to remain in VA for 5 years.
Program Results
Health Professions Scholarship
For academic years 2020/2021 and 2021/2022, 126 HPSP applications from both allopathic and osteopathic schools were submitted and 51 scholarships were awarded (Table 3). Assuming an average residency length of 4 years, VHA estimates that these awards will yield 204 service-year equivalents by 2029.
Veterans Healing Veterans
In the VHV program, scholarship recipients came from 5 Teague-Cranston schools; 2 at University of South Carolina, 2 at East Tennessee State University, 2 at Wright State University, 1 at Texas A&M College of Medicine, 1 at Marshall University; and 3 HBCUs; 2 at Howard University, 1 at Morehouse School of Medicine and 1 at Meharry Medical College. The Charles R. Drew University of Medicine and Science did not nominate any students for the scholarship. Assuming all recipients complete postgraduate training, the VHV scholarship program will provide an additional 12 veteran physicians to serve at VA for at least 4 years each (48 service years).
Specialty Education Loan Repayment
Fourteen applicants have been approved, including 5 in psychiatry, 4 in family medicine, 3 in internal medicine, 1 in emergency medicine, and 1 in geriatrics. The mean loan repayment is anticipated to be $110,000 and equating to 38.5 VA service years or a mean of 2.3 years of service obligation per individual for the first cohort. The program has no termination date, and with continued funding, VA anticipates granting 100 loan repayments annually.
Education Debt Reduction
Since 2018, 1,546 VA physicians have received EDRP awards. Due to the increased reimbursement provided through the MISSION Act, average physician award amounts have increased from $96,090 in 2018 to $142,557 in 2019 and $148,302 in 2020.
Conclusions
The VA physician scholarship and loan repayment programs outlined in the MISSION Act build on the success of existing federal scholarship programs by providing opportunities for physician trainees to alleviate educational debt and explore a VA health professions career.
Looking ahead, VA must focus on measuring the success of the MISSION scholarship and loan repayment programs by tracking rates of acceptance and student graduation, residency and fellowship completion, and placement in VA medical facilities—both for the service obligation and future employment. Ultimately, the total impact on VA staffing, especially at rural and underresourced sites, will determine the success of the MISSION programs.
As one of 4 statutory missions, the US Department of Veterans Affairs (VA) educates and trains health professionals to enhance the quality of and timely access to care provided to veterans within the Veterans Health Administration (VHA). To achieve its mission to
Despite its long-term success affiliating with medical schools, VA has continued to be challenged by physician staff shortages with wide variability in the number and specialty of available health care professionals across facilities.3,4 A 2020 VA Office of Inspector General report on VHA occupational staffing shortages concluded that numerous physician specialties were difficult to recruit due to a lack of qualified applicants, noncompetitive salary, and less desirable geographic locations.3
Federal health professions scholarship programs and loan repayment programs have long been used to address physician shortages.4 Focusing on physician shortages in underserved areas in the US, the Emergency Health Personnel Act of 1970 and its subsequent amendments paved the way for various federal medical school scholarship and loan repayment programs.5 Similarly, physician shortages in the armed forces were mitigated through the Uniformed Services Health Professions Revitalization Act of 1972 (USHPRA).6,7
In 2018, Congress passed the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act, which included sections designed to alleviate physician shortages in the VHA.8 These sections authorized scholarships similar to those offered by the US Department of Defense (DoD) and loan repayment programs. Section 301 created the Health Professions Scholarship Program (HPSP), which offers scholarships for physicians and dentists. Section 302 increased the maximum debt reduction through the Education Debt Reduction Program (EDRP). Section 303 authorizes the Specialty Education Loan Repayment Program (SELRP), which provides for repayment of educational loans for physicians in specialties deemed necessary for VA. Finally, Section 304 created the Veterans Healing Veterans (VHV), a pilot scholarship specifically for veteran medical students.
Program Characteristics
Health Professions Scholarship
The VA HPSP is a program for physicians and dentists that extends from 2020 to 2033. The HPSP funds the costs of tuition, fees, and provides a stipend with a service obligation of 18 months for each year of support. The program is authorized for 10 years and must provide a minimum of 50 scholarships annually for physicians or dentists based on VHA needs. Applications are screened based on criteria that include a commitment to rural or underserved populations, veteran status, grade point average, essays, and letters of recommendation. Although the minimum required number of scholarships annually is 50, VA anticipates providing 1000 scholarships over 10 years with an aim to significantly increase the number physicians at VHA facilities (Table 1).
Implemented in 2020, the VHV was a 1-year pilot program. It offered scholarships to 2 veterans attending medical school at each of the 5 Teague-Cranston and the 4 Historically Black College and University (HBCU) medical schools (Table 2). The intent of the program was to determine the feasibility of increasing the pool of veteran physicians at VHA. Eligible applicants were notified of the scholarship opportunity through the American Medical College Application Service or through the medical school. Applicants must have separated from military service within the preceding 10 years of being admitted to medical school. In exchange for full tuition, fees, a monthly stipend, and rotation travel costs, the recipients accepted a 4-year clinical service obligation at VA facilities after completing their residency training.
Specialty Education Loan Repayment
The SELRP is a loan repayment program available to recently graduated physicians. Applicants must have graduated from an accredited medical or osteopathic school, matched to an accredited residency program and be ≥ 2 years from completion of residency. The specialties qualifying for SELRP are determined through an analysis of succession planning by the VA Office of Workforce Management and Consulting and change based on VA physician workforce needs. The SELRP provides loan repayment in the amount of $40,000 per year for up to 4 years, with a service obligation of 1 year for each $40,000 of support. In April 2021, VA began accepting applications from the eligible specialties of family medicine, internal medicine, gastroenterology, psychiatry, emergency medicine, and geriatrics.
Education Debt Reduction
The EDRP offers debt relief to clinicians in the most difficult to recruit professions, including physicians (generalists and specialists), registered nurses, licensed practical nurses, social workers, and psychologists. The list of difficult to recruit positions is developed annually by VA facilities. Annual reimbursements through the program may be used for tuition and expenses, such as fees, books, supplies, equipment, and other materials. In 2018, through the MISSION Act Section 302, the annual loan repayment was increased from $24,000 to $40,000, and the maximum level of support was increased from $120,000 to $200,000 over 5 years. Recipients receive reimbursement for loan repayment at the end of each year or service period and recipients are not required to remain in VA for 5 years.
Program Results
Health Professions Scholarship
For academic years 2020/2021 and 2021/2022, 126 HPSP applications from both allopathic and osteopathic schools were submitted and 51 scholarships were awarded (Table 3). Assuming an average residency length of 4 years, VHA estimates that these awards will yield 204 service-year equivalents by 2029.
Veterans Healing Veterans
In the VHV program, scholarship recipients came from 5 Teague-Cranston schools; 2 at University of South Carolina, 2 at East Tennessee State University, 2 at Wright State University, 1 at Texas A&M College of Medicine, 1 at Marshall University; and 3 HBCUs; 2 at Howard University, 1 at Morehouse School of Medicine and 1 at Meharry Medical College. The Charles R. Drew University of Medicine and Science did not nominate any students for the scholarship. Assuming all recipients complete postgraduate training, the VHV scholarship program will provide an additional 12 veteran physicians to serve at VA for at least 4 years each (48 service years).
Specialty Education Loan Repayment
Fourteen applicants have been approved, including 5 in psychiatry, 4 in family medicine, 3 in internal medicine, 1 in emergency medicine, and 1 in geriatrics. The mean loan repayment is anticipated to be $110,000 and equating to 38.5 VA service years or a mean of 2.3 years of service obligation per individual for the first cohort. The program has no termination date, and with continued funding, VA anticipates granting 100 loan repayments annually.
Education Debt Reduction
Since 2018, 1,546 VA physicians have received EDRP awards. Due to the increased reimbursement provided through the MISSION Act, average physician award amounts have increased from $96,090 in 2018 to $142,557 in 2019 and $148,302 in 2020.
Conclusions
The VA physician scholarship and loan repayment programs outlined in the MISSION Act build on the success of existing federal scholarship programs by providing opportunities for physician trainees to alleviate educational debt and explore a VA health professions career.
Looking ahead, VA must focus on measuring the success of the MISSION scholarship and loan repayment programs by tracking rates of acceptance and student graduation, residency and fellowship completion, and placement in VA medical facilities—both for the service obligation and future employment. Ultimately, the total impact on VA staffing, especially at rural and underresourced sites, will determine the success of the MISSION programs.
1. VA Policy Memorandum #2. Policy in Association of Veterans’ Hospitals with Medical Schools. US Department of Veterans Affairs. January 20, 1946. Accessed February 17, 2022. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf 2. Gilman SC, Chang BK, Zeiss RA, Dougherty MB, Marks WJ, Ludke DA, Cox M. “The academic mission of the Department of Veterans Affairs.” In: Praeger Handbook of Veterans’ Health: History, Challenges, Issues, and Developments. Praeger; 2012:53-82.
3. Office of Inspector General, Veterans Health Administration OIG Determination of VHA Occupational Staffing Shortages FY2020. US Department of Veterans Affairs. Published September 23, 2020. Accessed February 17, 2022. https://www.va.gov/oig/pubs/VAOIG-20-01249-259.pdf
4. Hussey PS, Ringel J, et al. Resources and capabilities of the Department of Veterans Affairs to provide timely and accessible care to veterans. Rand Health Q. 2015;5(4). Accessed February 17, 2022. https://www.rand.org/content/dam/rand/pubs/research_reports/RR1100/RR1165z2/RAND_RR1165z2.pdf
5. Lynch A, Best T, Gutierrez SC, Daily JA. What Should I Do With My Student Loans? A Proposed Strategy for Educational Debt Management. J Grad Med Educ. 2018;10(1):11-15. doi:10.4300/JGME-D-17-00279.1
6. The Uniformed Services Health Professions Revitalization Act of 1972, PL 92-426. US Government Publishing Office. Published 1972. Accessed February 17, 2022. https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg713.pdf
7. Armed Forces Health Professions Financial Assistance Programs, 10 USC § 105 (2006).
8. ‘‘VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018’’. H.R. 5674. 115th Congress; Report No. 115-671, Part 1. May 3, 2018. Accessed February 17, 2022. https://www.congress.gov/115/bills/hr5674/BILLS-115hr5674rh.pdf
1. VA Policy Memorandum #2. Policy in Association of Veterans’ Hospitals with Medical Schools. US Department of Veterans Affairs. January 20, 1946. Accessed February 17, 2022. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf 2. Gilman SC, Chang BK, Zeiss RA, Dougherty MB, Marks WJ, Ludke DA, Cox M. “The academic mission of the Department of Veterans Affairs.” In: Praeger Handbook of Veterans’ Health: History, Challenges, Issues, and Developments. Praeger; 2012:53-82.
3. Office of Inspector General, Veterans Health Administration OIG Determination of VHA Occupational Staffing Shortages FY2020. US Department of Veterans Affairs. Published September 23, 2020. Accessed February 17, 2022. https://www.va.gov/oig/pubs/VAOIG-20-01249-259.pdf
4. Hussey PS, Ringel J, et al. Resources and capabilities of the Department of Veterans Affairs to provide timely and accessible care to veterans. Rand Health Q. 2015;5(4). Accessed February 17, 2022. https://www.rand.org/content/dam/rand/pubs/research_reports/RR1100/RR1165z2/RAND_RR1165z2.pdf
5. Lynch A, Best T, Gutierrez SC, Daily JA. What Should I Do With My Student Loans? A Proposed Strategy for Educational Debt Management. J Grad Med Educ. 2018;10(1):11-15. doi:10.4300/JGME-D-17-00279.1
6. The Uniformed Services Health Professions Revitalization Act of 1972, PL 92-426. US Government Publishing Office. Published 1972. Accessed February 17, 2022. https://www.govinfo.gov/content/pkg/STATUTE-86/pdf/STATUTE-86-Pg713.pdf
7. Armed Forces Health Professions Financial Assistance Programs, 10 USC § 105 (2006).
8. ‘‘VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018’’. H.R. 5674. 115th Congress; Report No. 115-671, Part 1. May 3, 2018. Accessed February 17, 2022. https://www.congress.gov/115/bills/hr5674/BILLS-115hr5674rh.pdf
The Expansion of Associated Health Training in the VA
The US Department of Veterans Affairs (VA) is the largest health care delivery system in the United States, comprising 1293 sites of care, including 171 medical centers.1 One of the 4 statutory missions of the VA is to train health care professionals (HCPs) to meet the needs of the VA and the nation.2 Through partnerships with more than 1800 accredited colleges, universities, and training programs, the VA provides training annually to nearly 118,000 health professions trainees (HPTs) across a variety of health care professions, and all of whom provide direct clinical care to veterans.3
In the VA, the Office of Academic Affiliations (OAA) is charged with overseeing health professions training and the VA’s partnership with medical and associated health (AH) professions schools, which was first codified in Policy Memorandum No. 2 in 1946.4,5 Given the scope and breadth of health professions education offered through the VA, OAA is in a unique position to address health care shortage areas as well as influence the educational standards for certain professions.
Many of these health care professions fall under the rubric of AH, which include mental health (MH) specialties, rehabilitative specialties, and others. These professions are critical to address in the expanding world of health care in the United States with its increased specialization and emphasis on coordination of care with interprofessional teams. During the 2019/2020 academic year, the VA provided clinical training to approximately 21,000 AH HPTs from > 40 professions with just over 20% receiving financial support through the OAA. Of the HPTs who train at VA without compensation, most spend shorter amounts of time in clinical rotations in the VA, are in pregraduate-degree education programs where payment for clinical rotations is not expected and may not be eligible for hire immediately on completion of their clinical training experience. The 17 funded professions have been strategically selected by the OAA to ensure a robust pipeline of HCPs to meet the needs of veterans and the nation.
To meet the demands of AH professionals (AHPs), the OAA implemented targeted expansion over the past 10 years. While not exhaustive, this paper describes several expansion efforts based on VA special initiatives, including enhancing clinical access in rural settings and shifting toward postgraduate-degree training and specialization. By aligning expansion with VA priorities as well as trends in health care more broadly, the OAA can ensure that there is a supply of well-trained AHPs who have developed the requisite competencies to contribute to our nation’s health care needs. Further, expansion can help train and recruit health professionals who can be hired into VA positions ready to care for the complex needs of veterans.
Associated Health Professionals
Overseen by the OAA, AH expansion is designed to address the specific needs of the VA and the US health care system. Data from the VA Workforce Management and Consulting (WMC) shows that the VA employment of AHPs has grown from 87,351 AHPs hired in fiscal year (FY) 2010 to 119,120 as of April 2020. This represents an average yearly growth rate of 3.4% and a total growth rate of 36%. The Bureau of Labor Statistics predictions for 2019/2029 suggest that certain AHPs are expected to have a 10-year growth rates of 20% or more to meet the changing health care needs of patients especially as the population ages; the growth rates for many AHPs far surpasses that of physicians, which is anticipated to be 4% (Table).6,7 The VA WMC expects an additional 52,283 AHPs will be hired by the VA by FY 2030 based on the 10-year average growth rate (Kali Clark, Veterans Health Administration Workforce Management and Consulting Office, email communication, May 28, 2020).
One of the driving forces behind the growth rate is the move toward using AHPs to supplement health care for a variety of health conditions.8,9 Examples include the integration of rehabilitation professionals, alternative care professionals (eg, massage therapists, practitioners who offer training in yoga and meditation), chiropractors, MH professionals, and pharmacists in the treatment of chronic pain, the use of a wider range of professionals in the treatment of MH conditions, and the integration of MH professionals into traditional medical settings, such as primary care. This intentional move to a more well-integrated model of interprofessional care is apparent in many other health care systems throughout the United States. Within the VA, this shift may be most evident through the introduction of the Whole Health model of care. The Whole Health model of care uses an interprofessional team to assess and care for veterans, using a personalized health plan addressing medical and MH conditions as well as behavioral, social, or spiritual concerns.10 The Whole Health model of care provides veterans with access to a variety of health care services, including but not limited to MH services, spiritual interventions, exercise-based programs, yoga, meditation, and nutrition counseling.
The OAA and AH education division have focused expansion to meet the increased need for MH and rehabilitation providers, to enhance interprofessional education, and to emphasize postgraduate-degree clinical training. This focus reflects the trends seen in health care training broadly throughout the nation and the intentional pivot is a model of these trends and a model for how to intentionally address these trends. Specific to the VA, focused expansion plans have allowed OAA to address VA strategic initiatives such as pain management and caring for rural veterans.
Funded Training Positions
As a result of recent AH expansion efforts, there has been a 33% increase in stipend-funded positions during the past 10 years, a rate that directly corresponds with the growth of AHPs in the VA. Recent AH expansion efforts can contribute to a particularly positive impact in highly rural and underserved areas where recruiting providers remains challenging.
The OAA launched the Mental Health Education Expansion (MHEE) initiative in 2012, which has now added 782 funded training slots across 10 health professions, 8 of which are psychology, pharmacy, chaplaincy, professional MH counseling, marriage and family therapy (MFT), social work (SW), occupational therapy (OT), and physician assistant (PA). Through the MHEE initiative, the VA has established funded internships for licensed professional mental health counselors and marriage and family therapists, as these professions are targeted for expanding the overall MH workforce in the VA. The OAA currently funds more than 50 total HPT positions for these 2 professions with an aim of increasing their recruitment to the VA MH workforce over the next decade. The MHEE is aligned with specified VA priorities to train a future VA workforce prepared for interprofessional collaboration and clinical care in an increasingly integrated and complex environment. This expansion effort also aligns with an increasing understanding of the importance of addressing the MH needs of our nation by ensuring there is an adequate supply of competent, well-trained clinicians entering the workforce.
The OAA has created and expanded residencies and fellowships in multiple rehabilitation professions, including chiropractic, physical therapy (PT), and OT. With the increased focus on the management of chronic pain in the nation combined with a specific emphasis on this clinical need in the VA, chiropractors have been deemed essential HCPs. In 2014, the VA established 5 chiropractic residency programs while partnering with the Council on Chiropractic Education to develop accreditation standards for residency training. OAA’s efforts have yielded 5 accredited residency programs, the first in the United States. In 2020, the VA doubled the number of available chiropractic residency programs, and future expansion is anticipated. Since 2010, PT residencies have expanded from 1 to 28 programs (42 funded positions) across 4 board certification specialties: cardiovascular-pulmonary, geriatric, neurologic, and orthopedic. Similarly, the VA was one of the first organizations to achieve accreditation for OT fellowships; there are currently 5 accredited OT fellowship programs across 3 areas of practice: assistive technology, MH, and physical rehabilitation. The VA OT fellowship program focused on assistive technology is the only program in the United States at this time.
Interprofessional Education
As one of the primary focus areas for AH expansion, interprofessional education (IPE) has been recognized as increasingly important for the provision of health care and the development of HPT programs. IPE can develop professionals who appreciate the roles of diverse professions and can use teamwork to enhance clinical outcomes for patients.11 There also are a growing number of professional organizations supporting the Interprofessional Education Collaborative with many representing AHPs.12 Collaboration across HCPs is an important way of reducing health care costs by enhancing clinical outcomes, communication, and teamwork.13-16 The VA and the nation’s health care system benefit from the by-products of interprofessional collaboration through investment in targeted training programs. In each phase of the AH expansion, special consideration was given to applicant programs offering unique and innovative clinical and educational experiences consistent with the promotion of interprofessional care. In doing so, increased numbers of AH HPTs have engaged in team-based clinical care.
Pain Management Pharmacy
The efforts of AH to align expansion with high-priority agency-wide efforts has resulted in the growth of pharmacy residency positions focused on pain management. Pharmacy postgraduate year (PGY) 2 residencies focusing on opioid reduction are an example of VA efforts to improve response to managing chronic pain and the long-term risks from opioid use during this national public health crisis.17 These residency programs focus on strategies to reduce the use of opioid medications in the clinical setting and teaching effective clinical interventions for reducing the rates of opioid addiction in veterans while still recognizing the need to identify and treat chronic pain. Before expansion efforts in 2018, there were 6 pharmacy residency programs focused on opioid use reduction in the VA, 8 pharmacy PGY2 residency positions were added in academic year 2019/2020, an additional 5 positions are being added in academic year 2021/2022 with the explicit goal of managing patients with high-risk chronic pain.
Rural Health
The lack of MH providers in rural areas has received much attention and is particularly important in the VA because veterans are more likely to live in less populated areas.18 The VA mandate to address this population was codified by the creation of the Office of Rural Health in 2006 via 38 USC § 7308.19Creating health professions training programs in rural settings provides HPTs the opportunity to learn professional competencies and train with faculty knowledgeable about this population—all of which provide a comprehensive training experience and serve as a recruitment pathway to hire HPTs into staff positions at these sites.19
When MHEE was initiated, not all regions of the country had funded VA psychology training programs, and this geographic gap in psychology training was a contributing factor to recruitment difficulties for psychologists in rural areas. As a result, the request for proposal process in the OAA highlighted and incentivized rurality when considering funding for new training programs. The OAA defined rurality as the number of patients served by the proposed health care facility who lived in a rural or highly rural zip code according to VA Support Service Center Capital Assets data.20 As a result, VA psychology doctoral internships expanded to be available in all states, the District of Columbia, and Puerto Rico. MH training programs were started in the highly rural states of Montana and Wyoming. These expansion efforts promise to be an essential component to addressing the gaps in coverage in rural settings as noted in recent research.21
Pregraduate to Postgraduate Programs
The OAA AH education division supports a significant number of pregraduate-degree and postgraduate-degree training. Some professions, such as psychology, pharmacy, SW, PT, speech pathology, OT, and nutrition/dietetics receive funding at both levels of training. More recent, the OAA has started to move funding from pregraduate to postgraduate-degree positions, specifically within professions where pregraduate funding is uncommon for both federal and nonfederal training positions. The effort is designed to better align stipend-paid training programs with the VA Professional Qualification Standards and the final level of training required for employment in the VA.22This means that HPTs receive stipend support during the highest level of their clinical training before degree conferral, eligibility for VA employment, or while participating in a postgraduate-degree residency or fellowship.
Additionally, this shift in focus and the resulting internal assessment of professions has allowed the OAA to fund more specialized training opportunities, which sometimes go beyond what is required by accrediting bodies or for recruitment into VA positions. For example, the OAA is supporting SW fellowship programs and PA residency positions to allow for greater specialization within these professions; the accrediting agencies for both professions have recently finalized their accreditation standards, and the OAA played a role in moving these standards forward.
While postgraduate residencies and fellowships are not required for all AH HPTs or for employment in the VA, there is a shift in some professions to encourage postgraduate training in advanced competencies in specialized areas. Participation in a residency or fellowship training program affords HPTs additional time and diverse clinical experiences to acquire clinical skills, all while under the supervision of a highly trained practitioner. This additional training also allows for a longitudinal assessment of the HPT to ensure an alignment of the HPTs’ knowledge, abilities, and skills with the expectation should they pursue VA employment.
In academic year 2019/2020, the OAA AH education division in conjunction with the PA national program office transitioned the entirety of the PA pregraduate-degree student positions (415 funded positions) to residency positions, increasing residency positions from 19 to 32 funded positions. This shift in emphasis for funding did not negatively impact the total number of pregraduate PA students receiving training in the VA and has created a pipeline of residency graduates who are ready to enter VA staff positions. To date, the VA has 14 PA residency programs across 3 specialties: emergency medicine (EM), MH, and primary care/geriatrics. Of these tracks, the VA offers 5 EM and 4 MH residencies that position graduates to be eligible for specialty certification. The National Commission on Certification of Physician Assistants established Certificates of Added Qualifications (CAQ) to recognize and document specialty knowledge, skills, and experience. The VA MH residency programs have been established to align with the CAQ expectations, and residents immediately qualify to take the CAQ examination after the completion of training.
Currently, the same process to move pregraduate to postgraduate funding is being implemented for PT and OT. Within the PT profession, there is increased momentum toward residency and fellowship training programs to respond to the changing complexity of the health care systemand reduce the need of complex care to be provided by non-VA providers in the community.23 Both PT and OT have entered the initial phases of transitioning to residency or fellowship-funded positions. The OAA is partnering with these professions to move positions to postgraduate degree within the next 3 years with a commensurate increase in funding. The initial data indicate that 80% of graduated VA PT residents are board-certification eligible, and 89% of those who are eligible passed the examination on their first attempt.
Since 2013, the VA psychology training also has realized a growth in postgraduate-degree residencies. Psychology residency positions have increased 99% to 453 funded positions. This growth represents increased specialization in neuropsychology, geropsychology, rehabilitation psychology, and health psychology. Additionally, postgraduate residencies meet most jurisdictional requirements for postdoctoral supervised experience and better prepare HPTs to enter specialty staff positions that are necessary to care for aging veterans.
Additional professions are being targeted for postgraduate-degree training programs, including dietetics and speech pathology, to align with upcoming changes in the qualification standards for employment. While the process to transition positions to postgraduate-degree training programs can take 3 to 5 years, the outcomes are expected to result in better prepared HPTs who can fill staff vacancies in the VA.
Conclusions
Through its funding and oversight of numerous professions, the OAA is uniquely situated to adapt its portfolio to meet the needs of the VA and the nation. Over the past 10 years, the OAA has expanded its total number of HPT positions to enhance interprofessional care, respond to the VA’s strategic initiatives, address the care needs of rural veterans, and shift positions to postgraduate training programs. The OAA’s investment in high-quality training programs builds a strong health care workforce ready to meet the needs of an increasingly complex and integrated health care environment.
The OAA anticipates future expansion, especially related to promoting rural training opportunities and shifting to postgraduate training programs as a means of promoting advanced health care and health system competencies while continuing to align with workforce projections. Furthermore, while there are data on the percentage of VA staff who participated in OAA training program through the VA All Employee Survey (AES), the range for AH professions is wide. For example, about 37% of rehabilitative staff reported participating in an OAA training program, and 72% of VA psychologists reported having an OAA training experience. To maximize the hiring of HPTs, OAA will continue its partnership with WMC to enact programs aimed at streamlining the hiring process so that veterans have access to HCPs who are specifically trained to work with them.
1. US Department of Veterans Affairs. Providing health care for veterans. Updated April 23, 2021. Accessed July 15, 2021. https://www.va.gov/health
2. Veterans’ Benefits. 38 USC §7301 and §7302 (1991). Accessed May 18, 2020. https://www.govinfo.gov/content/pkg/USCODE-2018-title38/pdf/USCODE-2018-title38-partV-chap73-subchapI-sec7302.pdf
3. US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations. Health professions education: academic year 2019-2020. Published 2021. Accessed July 15, 2021. https://www.va.gov/OAA/docs/OAA_Statistics_2020.pdf
4. US Department of Veterans Affairs, VHA Office of Academic Affiliations. VA Policy Memorandum # 2. Policy in association of veterans’ hospitals with medical schools. Published January 30, 1946. Accessed October 13, 2020. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf
5. US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations. Mission of the office of academic affiliations. Updated September 24, 2019. Accessed July 15, 2021. https://www.va.gov/oaa/oaa_mission.asp
6. US Bureau of Labor Statistics, Office of Occupational Statistics and Employment Projections Occupational Outlook Handbook. Healthcare occupations. Updated May 14, 2021. Accessed July 15, 2021. https://www.bls.gov/ooh/healthcare/home.htm
7. Windmill IM, Freeman BA. Demand for audiology services: 30-yr projections and impact on academic programs. J Am Acad Audiol. 2013;24(5):407-416. doi:10.3766/jaaa.24.5.7
8. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce. HRSA health workforce: behavioral health workforce projections, 2017-2030. Accessed July 15, 2021. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/bh-workforce-projections-fact-sheet.pdf
9. Centers for Disease Control and Prevention, National Center for Health Statistics. NCHS data brief, No. 325. Use of yoga, meditation, and chiropractors among US adults aged 18 and over. Published November 2018. Accessed September 24, 2020. https://www.cdc.gov/nchs/data/databriefs/db325-h.pdf
10. US Department of Veterans Affairs, Veterans Health Administration Whole Health. Updated July 6, 2021. Accessed July 15, 2021. https://www.va.gov/wholehealth
11. Clark KM. Interprofessional education: making our way out of the silos. Respir Care. 2018;63(5): 637-639. doi:10.4187/respcare.06234
12. Interprofessional Education Collaborative. What is interprofessional education (IPE)? Accessed July 15, 2021. https://www.ipecollaborative.org/about-us
13. Nester J. The importance of interprofessional practice and education in the era of accountable care. N C Med J. 2016;77(2):128-132. doi.10.18043/ncm.77.2.128
14.. Hardin L, Kilian A, Murphy E. Bundled payments for care improvement: preparing for the medical diagnosis-related groups. J Nurs Adm. 2017;47(6): 313-319. doi:10.1097/NNA.0000000000000492
15. Guraya SY, Barr H. The effectiveness of interprofessional education in healthcare: a systematic review and meta-analysis. Kaohsiung J Med Sci. 2018;34(2):125-184. doi:10.1016/j.kjms.2017.12.009
16. Ateah CA, Snow W, Wenter P, et al. Stereotyping as a barrier to collaboration: does interprofessional education make a difference? Nurse Educ Today. 2011;31(2):208-213. doi:10.1016/j.nedt.2010.06.004
17. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Managing Opioid Therapy for Chronic Pain. Published May 7, 1991. Updated February 2017. Accessed July 15, 2021. https://www.va.gov/HOMELESS/nchav/resources/docs/mental-health/substance-abuse/VA_DoD-CLINICAL-PRACTICE-GUIDELINE-FOR-OPIOID-THERAPY-FOR-CHRONIC-PAIN-508.pdf
18. US Department of Veterans Affairs, Office of Rural Health. VHA office of rural health. Updated March 17, 2021. Accessed July 15, 2021. https://www.ruralhealth.va.gov19. Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach. 2004;26(3):265-272. doi:10.1080/0142159042000192055
20. US Department of Veterans Affairs. VHA Support Service Center Capital Assets. Updated December 1, 2020. Accessed July 15, 2021. https://www.data.va.gov/dataset/VHA-Support-Service-Center-Capital-Assets-VSSC-/2fr5-sktm
21. Domino ME, Lin CC, Morrisey JP, et al. Training psychologists for rural practice: exploring opportunities and constraints. J Rural Health. 2019;35(1):35-41. doi:10.1111/jrh.12299
22. US Department of Veterans Affairs. VA Directive 5005: Staffing. Published March 4, 2020. Accessed July 15, 2021. https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1140&FType=2
23. Furze JA, Freeman BA. Physical therapy and fellowship education: reflections on the past, present, and future. Phys Ther. 2016;96(7):949-960. doi:10.2522/ptj.20150473
The US Department of Veterans Affairs (VA) is the largest health care delivery system in the United States, comprising 1293 sites of care, including 171 medical centers.1 One of the 4 statutory missions of the VA is to train health care professionals (HCPs) to meet the needs of the VA and the nation.2 Through partnerships with more than 1800 accredited colleges, universities, and training programs, the VA provides training annually to nearly 118,000 health professions trainees (HPTs) across a variety of health care professions, and all of whom provide direct clinical care to veterans.3
In the VA, the Office of Academic Affiliations (OAA) is charged with overseeing health professions training and the VA’s partnership with medical and associated health (AH) professions schools, which was first codified in Policy Memorandum No. 2 in 1946.4,5 Given the scope and breadth of health professions education offered through the VA, OAA is in a unique position to address health care shortage areas as well as influence the educational standards for certain professions.
Many of these health care professions fall under the rubric of AH, which include mental health (MH) specialties, rehabilitative specialties, and others. These professions are critical to address in the expanding world of health care in the United States with its increased specialization and emphasis on coordination of care with interprofessional teams. During the 2019/2020 academic year, the VA provided clinical training to approximately 21,000 AH HPTs from > 40 professions with just over 20% receiving financial support through the OAA. Of the HPTs who train at VA without compensation, most spend shorter amounts of time in clinical rotations in the VA, are in pregraduate-degree education programs where payment for clinical rotations is not expected and may not be eligible for hire immediately on completion of their clinical training experience. The 17 funded professions have been strategically selected by the OAA to ensure a robust pipeline of HCPs to meet the needs of veterans and the nation.
To meet the demands of AH professionals (AHPs), the OAA implemented targeted expansion over the past 10 years. While not exhaustive, this paper describes several expansion efforts based on VA special initiatives, including enhancing clinical access in rural settings and shifting toward postgraduate-degree training and specialization. By aligning expansion with VA priorities as well as trends in health care more broadly, the OAA can ensure that there is a supply of well-trained AHPs who have developed the requisite competencies to contribute to our nation’s health care needs. Further, expansion can help train and recruit health professionals who can be hired into VA positions ready to care for the complex needs of veterans.
Associated Health Professionals
Overseen by the OAA, AH expansion is designed to address the specific needs of the VA and the US health care system. Data from the VA Workforce Management and Consulting (WMC) shows that the VA employment of AHPs has grown from 87,351 AHPs hired in fiscal year (FY) 2010 to 119,120 as of April 2020. This represents an average yearly growth rate of 3.4% and a total growth rate of 36%. The Bureau of Labor Statistics predictions for 2019/2029 suggest that certain AHPs are expected to have a 10-year growth rates of 20% or more to meet the changing health care needs of patients especially as the population ages; the growth rates for many AHPs far surpasses that of physicians, which is anticipated to be 4% (Table).6,7 The VA WMC expects an additional 52,283 AHPs will be hired by the VA by FY 2030 based on the 10-year average growth rate (Kali Clark, Veterans Health Administration Workforce Management and Consulting Office, email communication, May 28, 2020).
One of the driving forces behind the growth rate is the move toward using AHPs to supplement health care for a variety of health conditions.8,9 Examples include the integration of rehabilitation professionals, alternative care professionals (eg, massage therapists, practitioners who offer training in yoga and meditation), chiropractors, MH professionals, and pharmacists in the treatment of chronic pain, the use of a wider range of professionals in the treatment of MH conditions, and the integration of MH professionals into traditional medical settings, such as primary care. This intentional move to a more well-integrated model of interprofessional care is apparent in many other health care systems throughout the United States. Within the VA, this shift may be most evident through the introduction of the Whole Health model of care. The Whole Health model of care uses an interprofessional team to assess and care for veterans, using a personalized health plan addressing medical and MH conditions as well as behavioral, social, or spiritual concerns.10 The Whole Health model of care provides veterans with access to a variety of health care services, including but not limited to MH services, spiritual interventions, exercise-based programs, yoga, meditation, and nutrition counseling.
The OAA and AH education division have focused expansion to meet the increased need for MH and rehabilitation providers, to enhance interprofessional education, and to emphasize postgraduate-degree clinical training. This focus reflects the trends seen in health care training broadly throughout the nation and the intentional pivot is a model of these trends and a model for how to intentionally address these trends. Specific to the VA, focused expansion plans have allowed OAA to address VA strategic initiatives such as pain management and caring for rural veterans.
Funded Training Positions
As a result of recent AH expansion efforts, there has been a 33% increase in stipend-funded positions during the past 10 years, a rate that directly corresponds with the growth of AHPs in the VA. Recent AH expansion efforts can contribute to a particularly positive impact in highly rural and underserved areas where recruiting providers remains challenging.
The OAA launched the Mental Health Education Expansion (MHEE) initiative in 2012, which has now added 782 funded training slots across 10 health professions, 8 of which are psychology, pharmacy, chaplaincy, professional MH counseling, marriage and family therapy (MFT), social work (SW), occupational therapy (OT), and physician assistant (PA). Through the MHEE initiative, the VA has established funded internships for licensed professional mental health counselors and marriage and family therapists, as these professions are targeted for expanding the overall MH workforce in the VA. The OAA currently funds more than 50 total HPT positions for these 2 professions with an aim of increasing their recruitment to the VA MH workforce over the next decade. The MHEE is aligned with specified VA priorities to train a future VA workforce prepared for interprofessional collaboration and clinical care in an increasingly integrated and complex environment. This expansion effort also aligns with an increasing understanding of the importance of addressing the MH needs of our nation by ensuring there is an adequate supply of competent, well-trained clinicians entering the workforce.
The OAA has created and expanded residencies and fellowships in multiple rehabilitation professions, including chiropractic, physical therapy (PT), and OT. With the increased focus on the management of chronic pain in the nation combined with a specific emphasis on this clinical need in the VA, chiropractors have been deemed essential HCPs. In 2014, the VA established 5 chiropractic residency programs while partnering with the Council on Chiropractic Education to develop accreditation standards for residency training. OAA’s efforts have yielded 5 accredited residency programs, the first in the United States. In 2020, the VA doubled the number of available chiropractic residency programs, and future expansion is anticipated. Since 2010, PT residencies have expanded from 1 to 28 programs (42 funded positions) across 4 board certification specialties: cardiovascular-pulmonary, geriatric, neurologic, and orthopedic. Similarly, the VA was one of the first organizations to achieve accreditation for OT fellowships; there are currently 5 accredited OT fellowship programs across 3 areas of practice: assistive technology, MH, and physical rehabilitation. The VA OT fellowship program focused on assistive technology is the only program in the United States at this time.
Interprofessional Education
As one of the primary focus areas for AH expansion, interprofessional education (IPE) has been recognized as increasingly important for the provision of health care and the development of HPT programs. IPE can develop professionals who appreciate the roles of diverse professions and can use teamwork to enhance clinical outcomes for patients.11 There also are a growing number of professional organizations supporting the Interprofessional Education Collaborative with many representing AHPs.12 Collaboration across HCPs is an important way of reducing health care costs by enhancing clinical outcomes, communication, and teamwork.13-16 The VA and the nation’s health care system benefit from the by-products of interprofessional collaboration through investment in targeted training programs. In each phase of the AH expansion, special consideration was given to applicant programs offering unique and innovative clinical and educational experiences consistent with the promotion of interprofessional care. In doing so, increased numbers of AH HPTs have engaged in team-based clinical care.
Pain Management Pharmacy
The efforts of AH to align expansion with high-priority agency-wide efforts has resulted in the growth of pharmacy residency positions focused on pain management. Pharmacy postgraduate year (PGY) 2 residencies focusing on opioid reduction are an example of VA efforts to improve response to managing chronic pain and the long-term risks from opioid use during this national public health crisis.17 These residency programs focus on strategies to reduce the use of opioid medications in the clinical setting and teaching effective clinical interventions for reducing the rates of opioid addiction in veterans while still recognizing the need to identify and treat chronic pain. Before expansion efforts in 2018, there were 6 pharmacy residency programs focused on opioid use reduction in the VA, 8 pharmacy PGY2 residency positions were added in academic year 2019/2020, an additional 5 positions are being added in academic year 2021/2022 with the explicit goal of managing patients with high-risk chronic pain.
Rural Health
The lack of MH providers in rural areas has received much attention and is particularly important in the VA because veterans are more likely to live in less populated areas.18 The VA mandate to address this population was codified by the creation of the Office of Rural Health in 2006 via 38 USC § 7308.19Creating health professions training programs in rural settings provides HPTs the opportunity to learn professional competencies and train with faculty knowledgeable about this population—all of which provide a comprehensive training experience and serve as a recruitment pathway to hire HPTs into staff positions at these sites.19
When MHEE was initiated, not all regions of the country had funded VA psychology training programs, and this geographic gap in psychology training was a contributing factor to recruitment difficulties for psychologists in rural areas. As a result, the request for proposal process in the OAA highlighted and incentivized rurality when considering funding for new training programs. The OAA defined rurality as the number of patients served by the proposed health care facility who lived in a rural or highly rural zip code according to VA Support Service Center Capital Assets data.20 As a result, VA psychology doctoral internships expanded to be available in all states, the District of Columbia, and Puerto Rico. MH training programs were started in the highly rural states of Montana and Wyoming. These expansion efforts promise to be an essential component to addressing the gaps in coverage in rural settings as noted in recent research.21
Pregraduate to Postgraduate Programs
The OAA AH education division supports a significant number of pregraduate-degree and postgraduate-degree training. Some professions, such as psychology, pharmacy, SW, PT, speech pathology, OT, and nutrition/dietetics receive funding at both levels of training. More recent, the OAA has started to move funding from pregraduate to postgraduate-degree positions, specifically within professions where pregraduate funding is uncommon for both federal and nonfederal training positions. The effort is designed to better align stipend-paid training programs with the VA Professional Qualification Standards and the final level of training required for employment in the VA.22This means that HPTs receive stipend support during the highest level of their clinical training before degree conferral, eligibility for VA employment, or while participating in a postgraduate-degree residency or fellowship.
Additionally, this shift in focus and the resulting internal assessment of professions has allowed the OAA to fund more specialized training opportunities, which sometimes go beyond what is required by accrediting bodies or for recruitment into VA positions. For example, the OAA is supporting SW fellowship programs and PA residency positions to allow for greater specialization within these professions; the accrediting agencies for both professions have recently finalized their accreditation standards, and the OAA played a role in moving these standards forward.
While postgraduate residencies and fellowships are not required for all AH HPTs or for employment in the VA, there is a shift in some professions to encourage postgraduate training in advanced competencies in specialized areas. Participation in a residency or fellowship training program affords HPTs additional time and diverse clinical experiences to acquire clinical skills, all while under the supervision of a highly trained practitioner. This additional training also allows for a longitudinal assessment of the HPT to ensure an alignment of the HPTs’ knowledge, abilities, and skills with the expectation should they pursue VA employment.
In academic year 2019/2020, the OAA AH education division in conjunction with the PA national program office transitioned the entirety of the PA pregraduate-degree student positions (415 funded positions) to residency positions, increasing residency positions from 19 to 32 funded positions. This shift in emphasis for funding did not negatively impact the total number of pregraduate PA students receiving training in the VA and has created a pipeline of residency graduates who are ready to enter VA staff positions. To date, the VA has 14 PA residency programs across 3 specialties: emergency medicine (EM), MH, and primary care/geriatrics. Of these tracks, the VA offers 5 EM and 4 MH residencies that position graduates to be eligible for specialty certification. The National Commission on Certification of Physician Assistants established Certificates of Added Qualifications (CAQ) to recognize and document specialty knowledge, skills, and experience. The VA MH residency programs have been established to align with the CAQ expectations, and residents immediately qualify to take the CAQ examination after the completion of training.
Currently, the same process to move pregraduate to postgraduate funding is being implemented for PT and OT. Within the PT profession, there is increased momentum toward residency and fellowship training programs to respond to the changing complexity of the health care systemand reduce the need of complex care to be provided by non-VA providers in the community.23 Both PT and OT have entered the initial phases of transitioning to residency or fellowship-funded positions. The OAA is partnering with these professions to move positions to postgraduate degree within the next 3 years with a commensurate increase in funding. The initial data indicate that 80% of graduated VA PT residents are board-certification eligible, and 89% of those who are eligible passed the examination on their first attempt.
Since 2013, the VA psychology training also has realized a growth in postgraduate-degree residencies. Psychology residency positions have increased 99% to 453 funded positions. This growth represents increased specialization in neuropsychology, geropsychology, rehabilitation psychology, and health psychology. Additionally, postgraduate residencies meet most jurisdictional requirements for postdoctoral supervised experience and better prepare HPTs to enter specialty staff positions that are necessary to care for aging veterans.
Additional professions are being targeted for postgraduate-degree training programs, including dietetics and speech pathology, to align with upcoming changes in the qualification standards for employment. While the process to transition positions to postgraduate-degree training programs can take 3 to 5 years, the outcomes are expected to result in better prepared HPTs who can fill staff vacancies in the VA.
Conclusions
Through its funding and oversight of numerous professions, the OAA is uniquely situated to adapt its portfolio to meet the needs of the VA and the nation. Over the past 10 years, the OAA has expanded its total number of HPT positions to enhance interprofessional care, respond to the VA’s strategic initiatives, address the care needs of rural veterans, and shift positions to postgraduate training programs. The OAA’s investment in high-quality training programs builds a strong health care workforce ready to meet the needs of an increasingly complex and integrated health care environment.
The OAA anticipates future expansion, especially related to promoting rural training opportunities and shifting to postgraduate training programs as a means of promoting advanced health care and health system competencies while continuing to align with workforce projections. Furthermore, while there are data on the percentage of VA staff who participated in OAA training program through the VA All Employee Survey (AES), the range for AH professions is wide. For example, about 37% of rehabilitative staff reported participating in an OAA training program, and 72% of VA psychologists reported having an OAA training experience. To maximize the hiring of HPTs, OAA will continue its partnership with WMC to enact programs aimed at streamlining the hiring process so that veterans have access to HCPs who are specifically trained to work with them.
The US Department of Veterans Affairs (VA) is the largest health care delivery system in the United States, comprising 1293 sites of care, including 171 medical centers.1 One of the 4 statutory missions of the VA is to train health care professionals (HCPs) to meet the needs of the VA and the nation.2 Through partnerships with more than 1800 accredited colleges, universities, and training programs, the VA provides training annually to nearly 118,000 health professions trainees (HPTs) across a variety of health care professions, and all of whom provide direct clinical care to veterans.3
In the VA, the Office of Academic Affiliations (OAA) is charged with overseeing health professions training and the VA’s partnership with medical and associated health (AH) professions schools, which was first codified in Policy Memorandum No. 2 in 1946.4,5 Given the scope and breadth of health professions education offered through the VA, OAA is in a unique position to address health care shortage areas as well as influence the educational standards for certain professions.
Many of these health care professions fall under the rubric of AH, which include mental health (MH) specialties, rehabilitative specialties, and others. These professions are critical to address in the expanding world of health care in the United States with its increased specialization and emphasis on coordination of care with interprofessional teams. During the 2019/2020 academic year, the VA provided clinical training to approximately 21,000 AH HPTs from > 40 professions with just over 20% receiving financial support through the OAA. Of the HPTs who train at VA without compensation, most spend shorter amounts of time in clinical rotations in the VA, are in pregraduate-degree education programs where payment for clinical rotations is not expected and may not be eligible for hire immediately on completion of their clinical training experience. The 17 funded professions have been strategically selected by the OAA to ensure a robust pipeline of HCPs to meet the needs of veterans and the nation.
To meet the demands of AH professionals (AHPs), the OAA implemented targeted expansion over the past 10 years. While not exhaustive, this paper describes several expansion efforts based on VA special initiatives, including enhancing clinical access in rural settings and shifting toward postgraduate-degree training and specialization. By aligning expansion with VA priorities as well as trends in health care more broadly, the OAA can ensure that there is a supply of well-trained AHPs who have developed the requisite competencies to contribute to our nation’s health care needs. Further, expansion can help train and recruit health professionals who can be hired into VA positions ready to care for the complex needs of veterans.
Associated Health Professionals
Overseen by the OAA, AH expansion is designed to address the specific needs of the VA and the US health care system. Data from the VA Workforce Management and Consulting (WMC) shows that the VA employment of AHPs has grown from 87,351 AHPs hired in fiscal year (FY) 2010 to 119,120 as of April 2020. This represents an average yearly growth rate of 3.4% and a total growth rate of 36%. The Bureau of Labor Statistics predictions for 2019/2029 suggest that certain AHPs are expected to have a 10-year growth rates of 20% or more to meet the changing health care needs of patients especially as the population ages; the growth rates for many AHPs far surpasses that of physicians, which is anticipated to be 4% (Table).6,7 The VA WMC expects an additional 52,283 AHPs will be hired by the VA by FY 2030 based on the 10-year average growth rate (Kali Clark, Veterans Health Administration Workforce Management and Consulting Office, email communication, May 28, 2020).
One of the driving forces behind the growth rate is the move toward using AHPs to supplement health care for a variety of health conditions.8,9 Examples include the integration of rehabilitation professionals, alternative care professionals (eg, massage therapists, practitioners who offer training in yoga and meditation), chiropractors, MH professionals, and pharmacists in the treatment of chronic pain, the use of a wider range of professionals in the treatment of MH conditions, and the integration of MH professionals into traditional medical settings, such as primary care. This intentional move to a more well-integrated model of interprofessional care is apparent in many other health care systems throughout the United States. Within the VA, this shift may be most evident through the introduction of the Whole Health model of care. The Whole Health model of care uses an interprofessional team to assess and care for veterans, using a personalized health plan addressing medical and MH conditions as well as behavioral, social, or spiritual concerns.10 The Whole Health model of care provides veterans with access to a variety of health care services, including but not limited to MH services, spiritual interventions, exercise-based programs, yoga, meditation, and nutrition counseling.
The OAA and AH education division have focused expansion to meet the increased need for MH and rehabilitation providers, to enhance interprofessional education, and to emphasize postgraduate-degree clinical training. This focus reflects the trends seen in health care training broadly throughout the nation and the intentional pivot is a model of these trends and a model for how to intentionally address these trends. Specific to the VA, focused expansion plans have allowed OAA to address VA strategic initiatives such as pain management and caring for rural veterans.
Funded Training Positions
As a result of recent AH expansion efforts, there has been a 33% increase in stipend-funded positions during the past 10 years, a rate that directly corresponds with the growth of AHPs in the VA. Recent AH expansion efforts can contribute to a particularly positive impact in highly rural and underserved areas where recruiting providers remains challenging.
The OAA launched the Mental Health Education Expansion (MHEE) initiative in 2012, which has now added 782 funded training slots across 10 health professions, 8 of which are psychology, pharmacy, chaplaincy, professional MH counseling, marriage and family therapy (MFT), social work (SW), occupational therapy (OT), and physician assistant (PA). Through the MHEE initiative, the VA has established funded internships for licensed professional mental health counselors and marriage and family therapists, as these professions are targeted for expanding the overall MH workforce in the VA. The OAA currently funds more than 50 total HPT positions for these 2 professions with an aim of increasing their recruitment to the VA MH workforce over the next decade. The MHEE is aligned with specified VA priorities to train a future VA workforce prepared for interprofessional collaboration and clinical care in an increasingly integrated and complex environment. This expansion effort also aligns with an increasing understanding of the importance of addressing the MH needs of our nation by ensuring there is an adequate supply of competent, well-trained clinicians entering the workforce.
The OAA has created and expanded residencies and fellowships in multiple rehabilitation professions, including chiropractic, physical therapy (PT), and OT. With the increased focus on the management of chronic pain in the nation combined with a specific emphasis on this clinical need in the VA, chiropractors have been deemed essential HCPs. In 2014, the VA established 5 chiropractic residency programs while partnering with the Council on Chiropractic Education to develop accreditation standards for residency training. OAA’s efforts have yielded 5 accredited residency programs, the first in the United States. In 2020, the VA doubled the number of available chiropractic residency programs, and future expansion is anticipated. Since 2010, PT residencies have expanded from 1 to 28 programs (42 funded positions) across 4 board certification specialties: cardiovascular-pulmonary, geriatric, neurologic, and orthopedic. Similarly, the VA was one of the first organizations to achieve accreditation for OT fellowships; there are currently 5 accredited OT fellowship programs across 3 areas of practice: assistive technology, MH, and physical rehabilitation. The VA OT fellowship program focused on assistive technology is the only program in the United States at this time.
Interprofessional Education
As one of the primary focus areas for AH expansion, interprofessional education (IPE) has been recognized as increasingly important for the provision of health care and the development of HPT programs. IPE can develop professionals who appreciate the roles of diverse professions and can use teamwork to enhance clinical outcomes for patients.11 There also are a growing number of professional organizations supporting the Interprofessional Education Collaborative with many representing AHPs.12 Collaboration across HCPs is an important way of reducing health care costs by enhancing clinical outcomes, communication, and teamwork.13-16 The VA and the nation’s health care system benefit from the by-products of interprofessional collaboration through investment in targeted training programs. In each phase of the AH expansion, special consideration was given to applicant programs offering unique and innovative clinical and educational experiences consistent with the promotion of interprofessional care. In doing so, increased numbers of AH HPTs have engaged in team-based clinical care.
Pain Management Pharmacy
The efforts of AH to align expansion with high-priority agency-wide efforts has resulted in the growth of pharmacy residency positions focused on pain management. Pharmacy postgraduate year (PGY) 2 residencies focusing on opioid reduction are an example of VA efforts to improve response to managing chronic pain and the long-term risks from opioid use during this national public health crisis.17 These residency programs focus on strategies to reduce the use of opioid medications in the clinical setting and teaching effective clinical interventions for reducing the rates of opioid addiction in veterans while still recognizing the need to identify and treat chronic pain. Before expansion efforts in 2018, there were 6 pharmacy residency programs focused on opioid use reduction in the VA, 8 pharmacy PGY2 residency positions were added in academic year 2019/2020, an additional 5 positions are being added in academic year 2021/2022 with the explicit goal of managing patients with high-risk chronic pain.
Rural Health
The lack of MH providers in rural areas has received much attention and is particularly important in the VA because veterans are more likely to live in less populated areas.18 The VA mandate to address this population was codified by the creation of the Office of Rural Health in 2006 via 38 USC § 7308.19Creating health professions training programs in rural settings provides HPTs the opportunity to learn professional competencies and train with faculty knowledgeable about this population—all of which provide a comprehensive training experience and serve as a recruitment pathway to hire HPTs into staff positions at these sites.19
When MHEE was initiated, not all regions of the country had funded VA psychology training programs, and this geographic gap in psychology training was a contributing factor to recruitment difficulties for psychologists in rural areas. As a result, the request for proposal process in the OAA highlighted and incentivized rurality when considering funding for new training programs. The OAA defined rurality as the number of patients served by the proposed health care facility who lived in a rural or highly rural zip code according to VA Support Service Center Capital Assets data.20 As a result, VA psychology doctoral internships expanded to be available in all states, the District of Columbia, and Puerto Rico. MH training programs were started in the highly rural states of Montana and Wyoming. These expansion efforts promise to be an essential component to addressing the gaps in coverage in rural settings as noted in recent research.21
Pregraduate to Postgraduate Programs
The OAA AH education division supports a significant number of pregraduate-degree and postgraduate-degree training. Some professions, such as psychology, pharmacy, SW, PT, speech pathology, OT, and nutrition/dietetics receive funding at both levels of training. More recent, the OAA has started to move funding from pregraduate to postgraduate-degree positions, specifically within professions where pregraduate funding is uncommon for both federal and nonfederal training positions. The effort is designed to better align stipend-paid training programs with the VA Professional Qualification Standards and the final level of training required for employment in the VA.22This means that HPTs receive stipend support during the highest level of their clinical training before degree conferral, eligibility for VA employment, or while participating in a postgraduate-degree residency or fellowship.
Additionally, this shift in focus and the resulting internal assessment of professions has allowed the OAA to fund more specialized training opportunities, which sometimes go beyond what is required by accrediting bodies or for recruitment into VA positions. For example, the OAA is supporting SW fellowship programs and PA residency positions to allow for greater specialization within these professions; the accrediting agencies for both professions have recently finalized their accreditation standards, and the OAA played a role in moving these standards forward.
While postgraduate residencies and fellowships are not required for all AH HPTs or for employment in the VA, there is a shift in some professions to encourage postgraduate training in advanced competencies in specialized areas. Participation in a residency or fellowship training program affords HPTs additional time and diverse clinical experiences to acquire clinical skills, all while under the supervision of a highly trained practitioner. This additional training also allows for a longitudinal assessment of the HPT to ensure an alignment of the HPTs’ knowledge, abilities, and skills with the expectation should they pursue VA employment.
In academic year 2019/2020, the OAA AH education division in conjunction with the PA national program office transitioned the entirety of the PA pregraduate-degree student positions (415 funded positions) to residency positions, increasing residency positions from 19 to 32 funded positions. This shift in emphasis for funding did not negatively impact the total number of pregraduate PA students receiving training in the VA and has created a pipeline of residency graduates who are ready to enter VA staff positions. To date, the VA has 14 PA residency programs across 3 specialties: emergency medicine (EM), MH, and primary care/geriatrics. Of these tracks, the VA offers 5 EM and 4 MH residencies that position graduates to be eligible for specialty certification. The National Commission on Certification of Physician Assistants established Certificates of Added Qualifications (CAQ) to recognize and document specialty knowledge, skills, and experience. The VA MH residency programs have been established to align with the CAQ expectations, and residents immediately qualify to take the CAQ examination after the completion of training.
Currently, the same process to move pregraduate to postgraduate funding is being implemented for PT and OT. Within the PT profession, there is increased momentum toward residency and fellowship training programs to respond to the changing complexity of the health care systemand reduce the need of complex care to be provided by non-VA providers in the community.23 Both PT and OT have entered the initial phases of transitioning to residency or fellowship-funded positions. The OAA is partnering with these professions to move positions to postgraduate degree within the next 3 years with a commensurate increase in funding. The initial data indicate that 80% of graduated VA PT residents are board-certification eligible, and 89% of those who are eligible passed the examination on their first attempt.
Since 2013, the VA psychology training also has realized a growth in postgraduate-degree residencies. Psychology residency positions have increased 99% to 453 funded positions. This growth represents increased specialization in neuropsychology, geropsychology, rehabilitation psychology, and health psychology. Additionally, postgraduate residencies meet most jurisdictional requirements for postdoctoral supervised experience and better prepare HPTs to enter specialty staff positions that are necessary to care for aging veterans.
Additional professions are being targeted for postgraduate-degree training programs, including dietetics and speech pathology, to align with upcoming changes in the qualification standards for employment. While the process to transition positions to postgraduate-degree training programs can take 3 to 5 years, the outcomes are expected to result in better prepared HPTs who can fill staff vacancies in the VA.
Conclusions
Through its funding and oversight of numerous professions, the OAA is uniquely situated to adapt its portfolio to meet the needs of the VA and the nation. Over the past 10 years, the OAA has expanded its total number of HPT positions to enhance interprofessional care, respond to the VA’s strategic initiatives, address the care needs of rural veterans, and shift positions to postgraduate training programs. The OAA’s investment in high-quality training programs builds a strong health care workforce ready to meet the needs of an increasingly complex and integrated health care environment.
The OAA anticipates future expansion, especially related to promoting rural training opportunities and shifting to postgraduate training programs as a means of promoting advanced health care and health system competencies while continuing to align with workforce projections. Furthermore, while there are data on the percentage of VA staff who participated in OAA training program through the VA All Employee Survey (AES), the range for AH professions is wide. For example, about 37% of rehabilitative staff reported participating in an OAA training program, and 72% of VA psychologists reported having an OAA training experience. To maximize the hiring of HPTs, OAA will continue its partnership with WMC to enact programs aimed at streamlining the hiring process so that veterans have access to HCPs who are specifically trained to work with them.
1. US Department of Veterans Affairs. Providing health care for veterans. Updated April 23, 2021. Accessed July 15, 2021. https://www.va.gov/health
2. Veterans’ Benefits. 38 USC §7301 and §7302 (1991). Accessed May 18, 2020. https://www.govinfo.gov/content/pkg/USCODE-2018-title38/pdf/USCODE-2018-title38-partV-chap73-subchapI-sec7302.pdf
3. US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations. Health professions education: academic year 2019-2020. Published 2021. Accessed July 15, 2021. https://www.va.gov/OAA/docs/OAA_Statistics_2020.pdf
4. US Department of Veterans Affairs, VHA Office of Academic Affiliations. VA Policy Memorandum # 2. Policy in association of veterans’ hospitals with medical schools. Published January 30, 1946. Accessed October 13, 2020. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf
5. US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations. Mission of the office of academic affiliations. Updated September 24, 2019. Accessed July 15, 2021. https://www.va.gov/oaa/oaa_mission.asp
6. US Bureau of Labor Statistics, Office of Occupational Statistics and Employment Projections Occupational Outlook Handbook. Healthcare occupations. Updated May 14, 2021. Accessed July 15, 2021. https://www.bls.gov/ooh/healthcare/home.htm
7. Windmill IM, Freeman BA. Demand for audiology services: 30-yr projections and impact on academic programs. J Am Acad Audiol. 2013;24(5):407-416. doi:10.3766/jaaa.24.5.7
8. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce. HRSA health workforce: behavioral health workforce projections, 2017-2030. Accessed July 15, 2021. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/bh-workforce-projections-fact-sheet.pdf
9. Centers for Disease Control and Prevention, National Center for Health Statistics. NCHS data brief, No. 325. Use of yoga, meditation, and chiropractors among US adults aged 18 and over. Published November 2018. Accessed September 24, 2020. https://www.cdc.gov/nchs/data/databriefs/db325-h.pdf
10. US Department of Veterans Affairs, Veterans Health Administration Whole Health. Updated July 6, 2021. Accessed July 15, 2021. https://www.va.gov/wholehealth
11. Clark KM. Interprofessional education: making our way out of the silos. Respir Care. 2018;63(5): 637-639. doi:10.4187/respcare.06234
12. Interprofessional Education Collaborative. What is interprofessional education (IPE)? Accessed July 15, 2021. https://www.ipecollaborative.org/about-us
13. Nester J. The importance of interprofessional practice and education in the era of accountable care. N C Med J. 2016;77(2):128-132. doi.10.18043/ncm.77.2.128
14.. Hardin L, Kilian A, Murphy E. Bundled payments for care improvement: preparing for the medical diagnosis-related groups. J Nurs Adm. 2017;47(6): 313-319. doi:10.1097/NNA.0000000000000492
15. Guraya SY, Barr H. The effectiveness of interprofessional education in healthcare: a systematic review and meta-analysis. Kaohsiung J Med Sci. 2018;34(2):125-184. doi:10.1016/j.kjms.2017.12.009
16. Ateah CA, Snow W, Wenter P, et al. Stereotyping as a barrier to collaboration: does interprofessional education make a difference? Nurse Educ Today. 2011;31(2):208-213. doi:10.1016/j.nedt.2010.06.004
17. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Managing Opioid Therapy for Chronic Pain. Published May 7, 1991. Updated February 2017. Accessed July 15, 2021. https://www.va.gov/HOMELESS/nchav/resources/docs/mental-health/substance-abuse/VA_DoD-CLINICAL-PRACTICE-GUIDELINE-FOR-OPIOID-THERAPY-FOR-CHRONIC-PAIN-508.pdf
18. US Department of Veterans Affairs, Office of Rural Health. VHA office of rural health. Updated March 17, 2021. Accessed July 15, 2021. https://www.ruralhealth.va.gov19. Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach. 2004;26(3):265-272. doi:10.1080/0142159042000192055
20. US Department of Veterans Affairs. VHA Support Service Center Capital Assets. Updated December 1, 2020. Accessed July 15, 2021. https://www.data.va.gov/dataset/VHA-Support-Service-Center-Capital-Assets-VSSC-/2fr5-sktm
21. Domino ME, Lin CC, Morrisey JP, et al. Training psychologists for rural practice: exploring opportunities and constraints. J Rural Health. 2019;35(1):35-41. doi:10.1111/jrh.12299
22. US Department of Veterans Affairs. VA Directive 5005: Staffing. Published March 4, 2020. Accessed July 15, 2021. https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1140&FType=2
23. Furze JA, Freeman BA. Physical therapy and fellowship education: reflections on the past, present, and future. Phys Ther. 2016;96(7):949-960. doi:10.2522/ptj.20150473
1. US Department of Veterans Affairs. Providing health care for veterans. Updated April 23, 2021. Accessed July 15, 2021. https://www.va.gov/health
2. Veterans’ Benefits. 38 USC §7301 and §7302 (1991). Accessed May 18, 2020. https://www.govinfo.gov/content/pkg/USCODE-2018-title38/pdf/USCODE-2018-title38-partV-chap73-subchapI-sec7302.pdf
3. US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations. Health professions education: academic year 2019-2020. Published 2021. Accessed July 15, 2021. https://www.va.gov/OAA/docs/OAA_Statistics_2020.pdf
4. US Department of Veterans Affairs, VHA Office of Academic Affiliations. VA Policy Memorandum # 2. Policy in association of veterans’ hospitals with medical schools. Published January 30, 1946. Accessed October 13, 2020. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf
5. US Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations. Mission of the office of academic affiliations. Updated September 24, 2019. Accessed July 15, 2021. https://www.va.gov/oaa/oaa_mission.asp
6. US Bureau of Labor Statistics, Office of Occupational Statistics and Employment Projections Occupational Outlook Handbook. Healthcare occupations. Updated May 14, 2021. Accessed July 15, 2021. https://www.bls.gov/ooh/healthcare/home.htm
7. Windmill IM, Freeman BA. Demand for audiology services: 30-yr projections and impact on academic programs. J Am Acad Audiol. 2013;24(5):407-416. doi:10.3766/jaaa.24.5.7
8. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce. HRSA health workforce: behavioral health workforce projections, 2017-2030. Accessed July 15, 2021. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/bh-workforce-projections-fact-sheet.pdf
9. Centers for Disease Control and Prevention, National Center for Health Statistics. NCHS data brief, No. 325. Use of yoga, meditation, and chiropractors among US adults aged 18 and over. Published November 2018. Accessed September 24, 2020. https://www.cdc.gov/nchs/data/databriefs/db325-h.pdf
10. US Department of Veterans Affairs, Veterans Health Administration Whole Health. Updated July 6, 2021. Accessed July 15, 2021. https://www.va.gov/wholehealth
11. Clark KM. Interprofessional education: making our way out of the silos. Respir Care. 2018;63(5): 637-639. doi:10.4187/respcare.06234
12. Interprofessional Education Collaborative. What is interprofessional education (IPE)? Accessed July 15, 2021. https://www.ipecollaborative.org/about-us
13. Nester J. The importance of interprofessional practice and education in the era of accountable care. N C Med J. 2016;77(2):128-132. doi.10.18043/ncm.77.2.128
14.. Hardin L, Kilian A, Murphy E. Bundled payments for care improvement: preparing for the medical diagnosis-related groups. J Nurs Adm. 2017;47(6): 313-319. doi:10.1097/NNA.0000000000000492
15. Guraya SY, Barr H. The effectiveness of interprofessional education in healthcare: a systematic review and meta-analysis. Kaohsiung J Med Sci. 2018;34(2):125-184. doi:10.1016/j.kjms.2017.12.009
16. Ateah CA, Snow W, Wenter P, et al. Stereotyping as a barrier to collaboration: does interprofessional education make a difference? Nurse Educ Today. 2011;31(2):208-213. doi:10.1016/j.nedt.2010.06.004
17. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Managing Opioid Therapy for Chronic Pain. Published May 7, 1991. Updated February 2017. Accessed July 15, 2021. https://www.va.gov/HOMELESS/nchav/resources/docs/mental-health/substance-abuse/VA_DoD-CLINICAL-PRACTICE-GUIDELINE-FOR-OPIOID-THERAPY-FOR-CHRONIC-PAIN-508.pdf
18. US Department of Veterans Affairs, Office of Rural Health. VHA office of rural health. Updated March 17, 2021. Accessed July 15, 2021. https://www.ruralhealth.va.gov19. Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach. 2004;26(3):265-272. doi:10.1080/0142159042000192055
20. US Department of Veterans Affairs. VHA Support Service Center Capital Assets. Updated December 1, 2020. Accessed July 15, 2021. https://www.data.va.gov/dataset/VHA-Support-Service-Center-Capital-Assets-VSSC-/2fr5-sktm
21. Domino ME, Lin CC, Morrisey JP, et al. Training psychologists for rural practice: exploring opportunities and constraints. J Rural Health. 2019;35(1):35-41. doi:10.1111/jrh.12299
22. US Department of Veterans Affairs. VA Directive 5005: Staffing. Published March 4, 2020. Accessed July 15, 2021. https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=1140&FType=2
23. Furze JA, Freeman BA. Physical therapy and fellowship education: reflections on the past, present, and future. Phys Ther. 2016;96(7):949-960. doi:10.2522/ptj.20150473