1500 New residencies through the V.A. Is this a step in the right direction?

[SuckySurgeon7]

https://www.aamc.org/advocacy/washh...efirststeptoaddressingvashortagesacademi.html

Originally emailed out to us in an AOA newsletter, and I like that it might kill two birds with one stone (GME shortage and lack of VA care).

For those who are only want the highlight reel:
"The agreement also provides $5 billion to hire, recruit, and train physicians. An annual report by the VA Office of Inspector General (OIG) will identify the five health provider occupations with the largest staffing shortages throughout VA and allow the VA to utilize direct hire authority to fill these positions in an expedited manner.

The bill instructs VA to add at least 1,500 graduate medical education (GME) residency slots over five years at VA facilities that are experiencing shortages or located within a federally designated Health Professions Shortage Area (HPSA). Allocation of these slots will be based on the OIG’s report, with a priority given to “residency positions and programs in primary care, mental health, and any other specialty the Secretary determines appropriate.” Priority is also given to VA facilities without existing GME programs and those in areas with a high concentration of veterans."

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[user3]

We need to learn from the law and pharmacy professions and be very careful with expanding GME spots.

 

[DrBowtie]

I can't think of a specialty that would be good to train exclusively within the VA system.

 

[SnowDoggy44]

I can't think of a specialty that would be good to train exclusively within the VA system.

Some of the surgical specialities could get a lot of good exposure and with supplementation from rotations at other sites outside of the VA has the makings of a decent and diverse caseload.

 

[Trogghunter]

That would be the most miserable experience during residency. The patient population isn't representative of the general American population, and the way that the VA works is nothing like a public/private hospital. Congrats, youll know how to treat old men with cancer.

 

[hallowmann]

I can't think of a specialty that would be good to train exclusively within the VA system.

Psychiatry?

The VA treats a lot of chronic illnesses as well. Plus, unfortunately it's patient population is getting younger, so maybe...

 

[DrBowtie]

Psychiatry?

The VA treats a lot of chronic illnesses as well. Plus, unfortunately it's patient population is getting younger, so maybe...

Urology and Psych would be ok but not very well rounded. Lack of significant female population.

 

[hallowmann]

Urology and Psych would be ok but not very well rounded. Lack of significant female population.

True. It could always be made more rounded with external rotations with major medical centers. I hope that is what actually happens though.

 

[SouthernSurgeon]

I can't think of a specialty that would be good to train exclusively within the VA system.

I don't think it would be exclusively within the VA

 

[hallowmann]

We need to learn from the law and pharmacy professions and be very careful with expanding GME spots.

To be fair a 1500 GME position increase means at most a 500 PGY1 position increase. Spread over 5 years, that's like 100 PGY1 positions added each year. That's what, an annual increase of 0.35% per year? Given that normal growth of GME is ~1% per year, which is, I believe still less than population increase, I doubt it'll make a big difference in the long-run.

 

[ChrisGriffen]

To be fair a 1500 GME position increase means at most a 500 PGY1 position increase. Spread over 5 years, that's like 100 PGY1 positions added each year. That's what, an annual increase of 0.35% per year? Given that normal growth of GME is ~1% per year, which is, I believe still less than population increase, I doubt it'll make a big difference in the long-run.

It wont make a difference in the long run at all. This is SDN though, and every time we have a thread about residency expansion some idiot has to mention the law school problem.

Its basically a requirement at this point.

 

[SouthernSurgeon]

To be fair a 1500 GME position increase means at most a 500 PGY1 position increase. Spread over 5 years, that's like 100 PGY1 positions added each year. That's what, an annual increase of 0.35% per year? Given that normal growth of GME is ~1% per year, which is, I believe still less than population increase, I doubt it'll make a big difference in the long-run.

I'm also not clear that this would actually be a "real" increase in GME positions.

Will the VA be creating new residency slots or will they use this money to entice existing residency programs to bring their residents to the VA?

I.e. since most programs are over their caps and have a number of unfunded slots, will this money simply be decreasing the number of unfunded slots?

 

[costales]

Here's the actual language:

(b) Increase of Graduate Medical Education Residency Positions-

(1) IN GENERAL- Section 7302 of title 38, United States Code, is amended by adding at the end the following new subsection:

`(e)(1) In carrying out this section, the Secretary shall establish medical residency programs, or ensure that already established medical residency programs have a sufficient number of residency positions, at any medical facility of the Department that the Secretary determines--

`(A) is experiencing a shortage of physicians; and

`(B) is located in a community that is designated as a health professional shortage area (as defined in section 332 of the Public Health Service Act (42 U.S.C. 254e)).

`(2) In carrying out paragraph (1), the Secretary shall--

`(A) allocate the residency positions under such paragraph among occupations included in the most current determination published in the Federal Register pursuant to section 7412(a) of this title; and

`(B) give priority to residency positions and programs in primary care, mental health, and any other specialty the Secretary determines appropriate.'.

(2) FIVE-YEAR INCREASE-

(A) IN GENERAL- In carrying out section 7302(e) of title 38, United States Code, as added by paragraph (1), during the 5-year period beginning on the day that is 1 year after the date of the enactment of this Act, the Secretary of Veterans Affairs shall increase the number of graduate medical education residency positions at medical facilities of the Department by up to 1,500 positions.

(B) PRIORITY- In increasing the number of graduate medical education residency positions at medical facilities of the Department under subparagraph (A), the Secretary shall give priority to medical facilities that--

(i) as of the date of the enactment of this Act, do not have a medical residency program; and

(ii) are located in a community that has a high concentration of veterans.​

 

[hawkeye pierce]

The residency spots are necessary if we are going to keep opening schools. Decreasing the number of school positions would be way more effective, or at least stopping growth.

 

[hallowmann]

The residency spots are necessary if we are going to keep opening schools. Decreasing the number of school positions would be way more effective, or at least stopping growth.

Effective at what though? I have no problem with stopping growth, but that's not really going to solve any real problems. We need something that makes the areas and fields that currently need doctors more desirable. At very least that involves a restructuring of GME.

We have saturation of specialists and docs in general in certain areas and a clear deficit in the bulk of the country. Ideally, we need to solve that problem, and we honestly can't do it by focusing on only one piece of it (e.g. opening more schools, expanding PC GME, or only paying PC docs more). We need a holistic approach . No idea what that approach is though...

 

[NurWollen]

Effective at what though? I have no problem with stopping growth, but that's not really going to solve any real problems. We need something that makes the areas and fields that currently need doctors more desirable. At very least that involves a restructuring of GME.

We have saturation of specialists and docs in general in certain areas and a clear deficit in the bulk of the country. Ideally, we need to solve that problem, and we honestly can't do it by focusing on only one piece of it (e.g. opening more schools, expanding PC GME, or only paying PC docs more). We need a holistic approach . No idea what that approach is though...

If SDN is at all representative, then most med students seem to be unaware of the existence of any place in America not named LA or New York City. It's going to be hard to get enough docs for middle America.

 

[SuckySurgeon7]

We have saturation of specialists and docs in general in certain areas and a clear deficit in the bulk of the country. Ideally, we need to solve that problem, and we honestly can't do it by focusing on only one piece of it (e.g. opening more schools, expanding PC GME, or only paying PC docs more). We need a holistic approach . No idea what that approach is though...

@Blue Dog posted a link to this Powerpoint a long time ago. The gist of it is that government reimbursements are determined via a committee of doctors (Relative Value Update Committee), but the committee is set up like the Senate rather than the House of Representatives: each specialty has a vote instead of giving out votes proportionally to the number of doctors in each specialty. All of the specialists vote as a block to receive high reimbursements for services like imaging and low reimbursements for "simple" office visits. The government has a set number of dollars to reimburse each year, so everyone goes into the meeting knowing that this is a zero sum game and you can't get more without taking from someone else. Because everyone eats from the same pie, the primary care docs get a smaller and smaller slice because the specialists can outvote them and gain a higher profit.

Bottom line: staffing the Relative Value Update Committee relative to the population of each profession would give primary care docs more power to negotiate for higher reimbursements.

http://healthcaredisclosure.org/docs/files/BodenheimerPaymentMay2006.pdf

 

[GUH]

If SDN is at all representative, then most med students seem to be unaware of the existence of any place in America not named LA or New York City. It's going to be hard to get enough docs for middle America.

A lot of medical schools discriminate against applicants from outside the area. Try applying to PNWUHS without connections to the Northwest, for example. I am very interested in working in a rural area but some programs I've looked into have policies restricting students from out of the area from rotating.
As long as they continue to discriminate, students from populated areas will continue to be discouraged from applying.

If this is true of residency as well (I don't know for sure but suspect it may be), then no wonder we stay far away.

 

[NurWollen]

A lot of medical schools discriminate against applicants from outside the area. Try applying to PNWUHS without connections to the Northwest, for example. I am very interested in working in a rural area but some programs I've looked into have policies restricting students from out of the area from rotating.
As long as they continue to discriminate, students from populated areas will continue to be discouraged from applying.

If this is true of residency as well (I don't know for sure but suspect it may be), then no wonder we stay far away.

Ironic isn't it? I'm from a large populous popular state and I'm worried rural residencies won't believe me when I say I'm genuinely interested in rural medicine.

 

[hallowmann]

A lot of medical schools discriminate against applicants from outside the area. Try applying to PNWUHS without connections to the Northwest, for example. I am very interested in working in a rural area but some programs I've looked into have policies restricting students from out of the area from rotating.
As long as they continue to discriminate, students from populated areas will continue to be discouraged from applying.

If this is true of residency as well (I don't know for sure but suspect it may be), then no wonder we stay far away.

That's just crazy. I hope they don't do that for residency. Especially if they have issues filling their spots. That's just shooting themselves in the foot. You might be better off applying ACGME in the area of that's how PNWUHS treats you. What about TRIs? Are they a bit more lenient with those?

 

[SouthernSurgeon]

@Blue Dog posted a link to this Powerpoint a long time ago. The gist of it is that government reimbursements are determined via a committee of doctors (Relative Value Update Committee), but the committee is set up like the Senate rather than the House of Representatives: each specialty has a vote instead of giving out votes proportionally to the number of doctors in each specialty. All of the specialists vote as a block to receive high reimbursements for services like imaging and low reimbursements for "simple" office visits. The government has a set number of dollars to reimburse each year, so everyone goes into the meeting knowing that this is a zero sum game and you can't get more without taking from someone else. Because everyone eats from the same pie, the primary care docs get a smaller and smaller slice because the specialists can outvote them and gain a higher profit.

Bottom line: staffing the Relative Value Update Committee relative to the population of each profession would give primary care docs more power to negotiate for higher reimbursements.

http://healthcaredisclosure.org/docs/files/BodenheimerPaymentMay2006.pdf

That's an oversimplification of how the RVU committee works.

For one, it's not like they just sit at a table and vote. They have a methodology they use - you can argue its merits but that's an entirely separate argument - they have to be able to provide CMS with some evidence to back up their relative value assignments.

For another, it's not like they review everything, every year. Have you ever seen a CPT coding book? There are far too many codes to go over in one year. They go through I believe 5 year cycles, and they also have mechanisms for special review of what CMS flags for potentially overused/overvalued services.

I'm not saying the committee is perfect or without bias/political interest. But the suggestion that the rich have just formed a voting bloc to keep themselves rich is silly. The committee's makeup, current progress, and methodology are all publicly available on the AMA website.

 

[SuckySurgeon7]

That's an oversimplification of how the RVU committee works.

For one, it's not like they just sit at a table and vote. They have a methodology they use - you can argue its merits but that's an entirely separate argument - they have to be able to provide CMS with some evidence to back up their relative value assignments.

For another, it's not like they review everything, every year. Have you ever seen a CPT coding book? There are far too many codes to go over in one year. They go through I believe 5 year cycles, and they also have mechanisms for special review of what CMS flags for potentially overused/overvalued services.

I'm not saying the committee is perfect or without bias/political interest. But the suggestion that the rich have just formed a voting bloc to keep themselves rich is silly. The committee's makeup, current progress, and methodology are all publicly available on the AMA website.

Thanks for the reply. I haven't looked at the AMA's website; I don't know what the agenda or methodology is for those meetings.

It still looks like the big issue comes down to the fact that the specialists and primary care docs eat from the same pie, and unless a large portion of specialist pay is reduced, primary care salaries will never be significantly raised. Perhaps the government ought to consider financial solutions outside of CMS reimbursements: increase loan payback programs at federally qualified healthcare centers, reduce the amount of time until the government pays the remainder of the loans, or allow better interest rates for primary care physicians.

What ideas would you have?

 

[Mad Jack]

That would be the most miserable experience during residency. The patient population isn't representative of the general American population, and the way that the VA works is nothing like a public/private hospital. Congrats, youll know how to treat old men with cancer.

It's probably going to be mostly FM, psych, and IM positions, likely working with community health centers and the like to round out patient populations. These aren't going to be perfect residencies, no doubt, but they're better than no residencies, particularly for IMGs and the like that would be happy to get any spot in the US.

 

[Mad Jack]

We need to learn from the law and pharmacy professions and be very careful with expanding GME spots.

We should be careful, certainly, but we're looking at tens of millions of more insured Americans, our elderly population increasing substantially, and the general population increasing by leaps and bounds faster than residencies have expanded. There's more than enough room for a 1500 total residency positions (keep in mind that this is total- they will amount to less than 500 extra residency spots per year, as the 1500 spots will be divided over mostly three and four year residencies).

 

[user3]

We should be careful, certainly, but we're looking at tens of millions of more insured Americans, our elderly population increasing substantially, and the general population increasing by leaps and bounds faster than residencies have expanded. There's more than enough room for a 1500 total residency positions (keep in mind that this is total- they will amount to less than 500 extra residency spots per year, as the 1500 spots will be divided over mostly three and four year residencies).

to play devil's advocate- many respond by arguing that midlevels would make up for such shortage.

But to be fair, there seems to be grumbling in about every specialty about job markets. They often seem to complain that their job market is already poor and that any increase in demand from population or healthcare law will be snatched by midlevels or curtailed via rationing...

 

[SuckySurgeon7]

to play devil's advocate- many respond by arguing that midlevels would make up for such shortage.

But to be fair, there seems to be grumbling in about every specialty about job markets. They often seem to complain that their job market is already poor and that any increase in demand from population or healthcare law will be snatched by midlevels or curtailed via rationing...

That thought is prevalent among us med students, but nurse practitioners cannot realistically take over primary care. What I've heard from others is that they don't have the same scope as a physician, a large proportion of them choose to go into specialties, and there are simply too few of them to come close to meeting the primary care gap. My personal opinion is that it's a heck of a lot easier to go to work for a specialist and make bank than be independent and cover your own malpractice, especially when you know that you just graduated and don't have the experience yet to go out on your own.

 

[hallowmann]

to play devil's advocate- many respond by arguing that midlevels would make up for such shortage.

But to be fair, there seems to be grumbling in about every specialty about job markets. They often seem to complain that their job market is already poor and that any increase in demand from population or healthcare law will be snatched by midlevels or curtailed via rationing...

The thing is, NPs also want to specialize and go to areas worth adequate or saturated healthcare markets (surprise, surprise they make the same decisions AMGs are making). I'm not too worried about that at this point. Not ideal, but it hasn't ruined primary care yet.

As far as docs complaining of job markets, I can tell you that I know a lot of people in path (one of the ones people repeatedly say is saturated). I know docs that come out of a path residency that easily make $200-$250k. Others do a forensics fellowship and easily find jobs in the $300-$350k range. The issue isn't that the markets across the board are saturated, its that very specific regions are saturated, where others have a deficit. No one wants to take that $250k job in the mid west. They prefer the $150k job in LA, NYC, etc. that have a ton of people applying for it.

 

[user3]

As far as docs complaining of job markets, I can tell you that I know a lot of people in path (one of the ones people repeatedly say is saturated). I know docs that come out of a path residency that easily make $200-$250k. Others do a forensics fellowship and easily find jobs in the $300-$350k range. The issue isn't that the markets across the board are saturated, its that very specific regions are saturated, where others have a deficit. No one wants to take that $250k job in the mid west. They prefer the $150k job in LA, NYC, etc. that have a ton of people applying for it.

interesting

 

[notbobtrustme]

Ironic isn't it? I'm from a large populous popular state and I'm worried rural residencies won't believe me when I say I'm genuinely interested in rural medicine.

do 4th year rotations in rural areas.