The Veterans Healthcare Administration (VHA) is the largest health care delivery system
in the United States. It includes 172 medical centers (VAMCs), with over 1,100 Community
Based Outpatient Centers (CBOCs) and various other sites of care. In addition to training
physicians to care for veterans and active duty service members, the VHA is also directed
to assist in supplying health care personnel to the nation.
Through its Office of Academic Affiliations (OAA), VHA develops partnerships with
Accreditation Council for Graduate Medical Education (ACGME)/American Osteopathic
Association (AOA) accredited residency program sponsoring institutions. These collaborations
include 144 out of 152 allopathic medical schools and all 34 osteopathic medical schools.
Through partnerships, in 2018, VHA provided training to 45,296 medical residents,
24,643 medical students, and many other associated health profession trainees.1
The gap between supply and demand of physicians continues to grow.2, 3 This is particularly
significant in rural areas. US Census data show that a higher percentage of veterans
live in rural areas than all Americans (24% vs 19.3%).4, 5 Compared to urban veterans,
they experience higher disease prevalence and lower physical and mental quality‐of‐life
scores.6 Addressing the problem of physician shortages is a mission‐critical priority
for the VHA.7 In response, Section 301b of the Veterans Access, Choice, and Accountability
Act of 2014 (VACAA),8 amended by Section 617 of the Veterans Healthcare Benefits Improvement
Act of 2016,9 requires VHA to fund up to 1,500 new graduate medical education (GME)
positions by August 7, 2024. Although VHA has already approved 1,055 of these, only
67.5 resident positions (6.4%) are in self‐designated rural sites. The VACAA effort
has revealed difficulty in expanding GME in rural areas due to a dearth of partnership
options, infrastructure funding difficulties, and a lack of incentives for residents
to train in rural and underserved areas.10
In June of 2018, Public Law 115–182, known as the John S. McCain III, Daniel K. Akaka,
and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated
Outside Networks Act of 2018 (VA MISSION Act),11 was passed. The primary purpose of
the VA MISSION Act is to establish an effective and more efficient community care
program for veterans and create a framework through which to modernize and realign
the resources of the VHA. The Act provides $5.2 billion to expand access to community
care through the Veterans Choice Fund, while sunsetting some limitations described
in section 101 of the VACAA (PL 113–146).8
The VA MISSION Act of 2018 has 2 distinct aspects. Two of the 5 titles aim to improve
veteran access to care by expanding community options and creating a commission to
modernize and streamline VHA infrastructure. The remaining 3 titles mandate innovations
designed to redistribute medical personnel, specialized services, and GME to rural
and underserved locations throughout the United States.
Title I focuses on improvements to health care delivery including expansion of telehealth
authority, expansion of the family caregiver program, and a new authority to support
the cost of live donor transplant care for veteran recipients. Provisions to improve
communications, payments, and collections between VHA, insurers, and community providers
are included, as are training, competency, and continuing education requirements for
non‐VA health care professionals. It also authorizes creation of a “Center for Innovation
for Care and Payment” to innovate through the use of pilot programs that could be
extended or modified to improve quality, access, or cost savings.
Title II of the Act also establishes a commission to comprehensively review VHA infrastructure
and assets, and to modernize, realign, and close facilities strategically. There has
been some controversy because of concerns that VA facility closures could lead to
loss of services for veterans in affected areas. Nevertheless, VA's large footprint
of both buildings and land would likely benefit from a systematic review.
Title III offers new options for VHA to recruit physicians and dentists into rural
and underserved areas. Two new scholarship opportunities and a Specialty Education
Loan Repayment program are created, and funding is increased for the current Education
Debt Reduction Program.
1) Health Professional Scholarship Program for Physicians and Dentists (HPSP). After
regulations are established, 2‐ to 4‐year medical or dental school scholarships (tuition,
fees, and stipend) will be offered in exchange for VHA service. This scholarship will
function similarly to the HPSP offered through the Department of Defense (DoD), but
with a longer repayment period (18 months/year for VHA vs 12 months/year for DoD).
After completing the residency (and possibly fellowship) of their choice, participants
would be given a VHA assignment in an area of the United States experiencing a critical
need that matches their specialty training. The number of scholarships available will
be based on VHA‐determined provider shortages. This authority is set to expire in
2035.
2) “Veterans Healing Veterans” Medical Access and Scholarship Program. This pilot
program provides 4 years of tuition, fees, and stipend support for 2 veterans at each
of the 5 Teague‐Cranston medical schools,1 and the 4 historically black medical schools2
in exchange for 4 years of clinical practice at a VA facility after completion of
a residency and/or fellowship. The Teague‐Cranston Act of 1972 created 5 medical schools
in conjunction with established VA Medical Centers to provide care to veterans and
community members in rural and other medically underserved areas of the United States.
3) The Specialty Loan Repayment program offers $40,000 per 12 months of clinical service
in VHA to physicians in residency training, with a maximum repayment of $160,000.
To be eligible, residents/fellows must have 2 or more years remaining in training.
Preference will be given to residents who are veterans, and residents training in
rural areas, operated by Indian tribes, Indian Health Service, or affiliated with
underserved health care facilities. The recipients could then select their location
of service from a list of approved VHA facilities.
Title IV of the VA MISSION Act requires the development of criteria to designate VA
Medical Centers as underserved facilities and a plan to address their needs. It also
enables a pilot program to furnish mobile deployment teams of needed medical personnel
to these facilities. In addition, Title IV, section 403 creates a pilot program with
2 new authorities to increase physician training in underserved areas.
The first authority enables VA‐paid residents to provide care in “covered” federal
facilities outside of the traditional VA campus. Using positions created through VACAA,
at least 100 residents will train in facilities of the Indian Health Service, tribal
health care organizations, or designated underserved VA areas, augmenting both the
current health care workforce, and creating a new workforce pipeline. Federally Qualified
Health Centers and DoD medical centers are included on the list of covered facilities
as potential resident training locations.
The second new authority gives VHA the ability to assist with development costs of
new residency programs starting in VA‐designated underserved communities. It will
take about 18 months to develop regulations that will guide the enactment of this
portion of the legislation and determine how to evaluate these pilot projects.
Title V includes a potpourri of various non‐GME‐related topics including incorporating
peer specialists within Patient Aligned Care Teams (PACT),12 clarifying the role of
VA podiatrists, and a pilot project to use medical scribes to improve patient access
in various medical settings. This section also modifies the definition of major facility
projects, and it appropriates the aforementioned $5.2 billion to the Veterans Choice
Fund.
Overall, the VA MISSION Act will be a “game changer” in bringing GME to rural areas.
Titles III and IV specifically address difficulties identified during the implementation
of the prior VACAA effort—namely, the complexity of expanding GME in rural areas due
to a dearth of partnership options, infrastructure funding difficulties, and a lack
of incentives for residents to train in rural and underserved areas.10 Given that
physicians who choose to train in rural areas often remain in those areas for some
time after completing their training,13 the VA MISSION Act should lead to a greater
number of physicians to serve veterans in rural America. We (the authors) believe
these new authorities can potentially improve rural continuity of care, aid VHA in
filling chronically vacant physician positions, and create a new workforce pipeline
to benefit both veterans and communities alike. The pilot projects in section 403
will allow VHA to explore funding GME training off the traditional VA campus at Indian
Health Service, other tribal health care facilities, and other underserved veteran
communities. Implementation of the programs described above is contingent on federal
funding. The VA MISSION Act of 2018 brings welcomed flexibility to VHA in fulfilling
its missions to “give veterans the highest quality medical care,” “affording the medical
veteran the opportunity for postgraduate study, which he was compelled to forgo in
serving his country,” and “raising generally the standard of medical practice in the
United States by the expression of facilities for graduate education.”14