Carolyn M. Clancy, MD
Deputy Under Secretary for Health for Organizational Excellence
Special Address
VA Health Care:
Past, Present, Future and the Role of Academic Internal Medicine
Association of Professors of Medicine - Winter Meeting
February 26, 2016
VA and Academic Internal Medicine
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Celebrating 70 Years of Partnership
Our Shared Tripartite Mission
“Striving for Excellence Together”
Your Thoughts / Reactions
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Good News Story from VA
Recent study by Nuti et al. in 2/9/2016 JAMA
 Mortality rates for older men treated for AMI or heart failure at VA
hospitals were lower compared with those treated at non-VA
hospitals
 “These findings are important because they suggest that despite all
of the challenges that VA hospitals have faced, they are still able to
deliver high-quality care for some of the sickest, most complicated
patients.”
(
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Celebrating 70 Years of Partnership
“The
Department of Medicine and
Surgery of the Veterans'
Administration is embarking upon
a program that is without
precedent in the history of Federal
hospitalization….There can be no
doubt of the good faith of both
parties.”
(Memorandum No. 2)
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Carolyn, which
academic affiliates
are VA’s ‘top ten’?
I’ll go over
that list
right now.
Our Shared Tripartite Mission:
Education
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Graduate Medical Education
Current Scope
• Over 40,000 physician residents rotate through 10,200
FTEE salary lines (3 to 4 residents per FTEE)
o 1/3 of all US allopathic residents
• Over $650 million dollars in funding
• Most complexity 1a, 1b & 1c facilities have GME
programs; few complexity 2 & 3 facilities have GME
programs
• GME has always been seen as a “big facility” endeavor
but things are changing rapidly
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Financing Graduate Medical Education
2010 MedPAC Report
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Veterans Access, Choice, &
Accountability Act (VACAA)
• PL 113-146: Enacted by Congress & signed by
the President on August 7, 2014 – Section 301(b)
o Provision to expand VA GME by “up to 1,500
positions” over 5 years beginning 1 year after
signing
o Funding priorities defined (next slide)
o Annual Congressional reporting requirements
regarding the filled VACAA positions and their
VA locations
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Funding Priorities in VACAA
Facility Characteristics
Program Characteristics
• A shortage of
physicians
• No prior GME
• Areas with a “high
concentration of
Veterans”
• Health Professional
Shortage Areas
(HPSAs) as defined by
HRSA
• Primary Care
• Mental Health
• Other specialties “the
Secretary deems
appropriate” (interpreted
as those specialties
having excessive wait
times for care)
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Legislative Priorities Require Different
GME Emphasis
• VACAA GME authority can be used as leverage to
assist with US physician maldistribution and subspecialty predominance
• Working with community partners, VA GME
expansion can greatly impact smaller communities
and smaller VAMCs by
o Increasing the local workforce pipeline
o Over 60% of GME participants stay within 100 miles of
their training location post-residency
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Legislative Priorities Require Different
GME Outreach
• VACAA GME Priorities create opportunities for
o Outreach to Osteopathic Medical Schools & Osteopathic
Postdoctoral Training Institutions Outreach to Family
Medicine Community Based Programs
o Outreach to partnerships with Federally Qualified Health
Centers and Teaching Health Centers
o Outreach to Rural Track Training Programs
o Partnerships with Complexity Level 2 and 3 VAMCs
o Partnerships for training in Community Based Outpatient
Clinics and Health Care Centers with all size VAMCS
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YEAR 1: VA GME Expansion Requests
Approved for AY 2015-16
Focus
Approved
Positions
% of Total
Primary Care
102.4
50%
Mental Health
57.8
28%
Critical Needs
44
22%
204.2
100%
Total
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YEAR 2: VA GME Expansion Requests
Approved for AY 2016-17
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Expanding Graduate Medical
Education
• VA cannot expand GME by itself - we do not
create our own residency programs
• Community partners will be vital to assist with
identifying expansion opportunities that meet the
legislative priorities
• Smaller VAMCs may need assistance to “get
into the GME game”
• OAA has budgeted for extensive financial
assistance to start up fledgling GME programs
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Types of Assistance
 Planning Grants
 VACAA Direct Resident Stipend and Benefit
Payments
 Infrastructure Grants – to offset costs of protected
time for faculty, recruitment of an experienced DEO,
education office staffing, minor space modifications
and construction, faculty development
 Extensive OAA consultation
 Site Visits
 Partner Matching Services
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GME – PROs and CONs
PROs
CONs
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Brings a brand new workforce pipeline
into your facility and community –
improves recruitment
Faculty responsibilities foster
recruitment of higher quality medical
staff members
Allows expansion of scope of health
care programs for Veterans and
access for Veterans
Academic culture enhances evidencebased practice, improving quality of
care
Academic PACT improves staff and
trainee satisfaction with primary care
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Current staff members may need
faculty development to learn
supervision and teaching skills
New staff may need to be recruited to
do GME well
Residents may slow productivity at
early stages, but improve staff
productivity as they learn
Need protected time for supervising
and teaching faculty
Need a Site Director, DEO, and staff
assistance to run GME – costs $$
Our Shared Tripartite Mission:
Research
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VA Research:
90 Years of Innovation
Mission: To discover knowledge and create innovations that
advance the health care of Veterans and the Nation.
Budget:
Medical & Prosthetics Research
$631 million (FY2016)
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VA Research:
90 Years of Innovation
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
Nation’s only federal intramural research
program focused entirely on Veterans’ health
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More than 60 percent of VA investigators also
provide direct patient care
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3 Nobel prizes, 7 Lasker awards, among
numerous other distinctions
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Full integration of basic, clinical, and applied
research
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Career Development Program to mentor junior
investigators
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Extensive human subjects protection program
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Cooperative Studies Program and VA Central
Institutional Review Board, which enable VA
investigators to conduct large, multisite clinical
trials.
VA Research:
90 Years of Innovation (cont’d)
• Conducted first-of-its-kind study to optimize design of advanced
prosthetic “DEKA” arm
• Showed effectiveness of new vaccine for shingles
• Reported on major advances in BrainGate, a brain-computer
interface system that enables patients w/ paralysis to operate a
robotic arm using their thoughts
• Demonstrated that prolonged exposure therapy is more effective for
diabetes than multiple daily injections
VETERANS HEALTH ADMINISTRATION
VA Research:
90 Years of Innovation
• Demonstrated that an aspirin per day reduced by half the rate of
death and nonfatal heart attacks in patients with unstable angina
• Developed nicotine patch and other therapies to support smoking
cessation
• Invented implantable cardiac pacemaker
• Developed and tested therapies for tuberculosis
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Research to Improve the Lives of Veterans:
From Previous Generations of Veterans……
Aging
Diabetes
Alzheimer’s/Dementia
Gulf War
Cancer
Hearing/Vision Loss
Cardiovascular Disease &
Hypertension
Long-Term Health Outcomes
Parkinson’s Disease
Complementary & Alternative
Medicine
Prosthetics & Rehabilitation
Depression/Mental Health
Spinal Cord Injury
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…to the Newest Generation of Veterans
Returning Home
Burns
Employment/Vocational Rehabilitation
Family/Caregiver Issues
Homelessness
Pain Management
PTSD
Substance Use Disorders
TBI/Neurotrauma/Polytrauma
Women’s Health
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Research to Ensure High Quality Care
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Access to Care/Rural Health
Comparative Effectiveness Research
Health Information Technology
Telehealth
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New Areas of Study:
Genomics
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
Launched in 2011, MVP invites nationwide
users of VA’s health care system to partner
with the Department in an effort to better
understand how genes affect health.
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MVP will create one of the world’s largest
genetic and health databases, and will
enable researchers to conduct important
studies on a range of health conditions
affecting Veterans and others.
VA-Academic Research Partnership
Improving Post-Stroke Fitness and Movement
Baltimore VAMC/Univ. of Maryland SOM
Human Engineering Research Laboratories (VA Center of Excellence in
Wheelchairs and Associated Rehabilitation Engineering)
VA Pittsburgh Healthcare System/University of Pittsburgh SOM
Nasal Insulin Spray for Alzheimer’s Disease
VA Puget Sound Healthcare System/Univ. of Washington SOM
Telemedicine and Depression
Central Arkansas Veterans Healthcare System/ Univ. of Arkansas for
Medical Sciences
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Our Shared Tripartite Mission:
Clinical Care
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QUERI Choice Act Projects
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In-depth Evaluation of Implementation, Access, Outcomes in 3
Sites (VA Eastern Colorado Healthcare System)
OEF/OIF/OND Veterans' Utilization Trends for Primary & Specialty Care
(VA Palo Alto Healthcare System)
Quality of Care/Care Coordination (VA Ann Arbor Healthcare
System)
Care Coordination for Women Veterans (VA Central Western
Massachusetts Healthcare System)
Veteran Satisfaction with Choice, and Impact on Pharmacy Benefits (VA
Pittsburgh Healthcare System)
Appropriateness of Opioid Therapy (West Haven VA)
Issues Facing Veterans with PTSD (South Texas Veterans Healthcare
System)
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VCA Implementation, Access, & Outcomes
VA Eastern Colorado Healthcare System
Goal: Determine if the Choice Act is working in rural areas
Methods:
• Quantitative data on wait times and geospatial data
• Lean Six Sigma Analysis via qualitative interviews to identify
implementation gaps
Findings:
• Geospatial evaluation showed majority of TPA non-specialty
providers within existing 40 mile service areas
• However, value stream mapping, interviews found barriers
including lack of specialty providers, poor data exchanges
between VA and TPA
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Quality of Care/Care Coordination
VA Ann Arbor Healthcare System
Goal: Develop and refine quality measures (including overuse
and patient-centered care) for chronic conditions
Methods:
• Interactive voice response phone survey tool, chart review
tool to assess quality of care for Veterans in VCA
• Measured underuse, overuse of care for major chronic
conditions in PC (HTN, hyperlipidemia, DM, depression)
• Veteran interviews using automated methods to refine
metrics of care access and coordination
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Health Care Is at a Critical
“Fork in the Road”
Do we continue down a
path that frustrates
clinicians, confuses
patients and doesn’t
consistently align
incentives with improving
quality and value?
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Do we align quality and
value efforts with care
where it matters, at the
front line with clinicians
and patients?
Striving for Excellence Together
Common Challenges:
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Access
Shift from Inpatient to Outpatient Care
New Approaches to Emerging Needs
Patient Engagement
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Common Challenges:
Access
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What Patient Surveys Tell Us:
VA is significantly better in comprehensiveness,
but lags in access.
Private Sector (CAHPS Composite)1
Access (based on % always getting care when needed)
(adjusted for differences in age,
education, and health status)
6 points lower than private sector
Communication
About the same
Provider Discusses Medical Decisions
About the same
Self-Management Support
About the same
Comprehensiveness (attending to mental and emotional
health as well as physical health)
Office Staff
1Source:
6 points higher than private sector
About the same
Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys
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Common Challenges:
From Inpatient to Outpatient Care
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Common Challenges:
New Approaches to Emerging Needs
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Common Challenges:
“Cowboys and Pit Crews”
The New Yorker
(2011 Harvard Medical School Commencement
Address, as reprinted by The New Yorker)
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Common Challenges:
How Do We Engage Patients?
• Patient-centeredness is the most
challenging of the IOM’s six
domains of quality
• But it’s the most important,
because it contains elements of
all other domains
• Two requests to make of patients:
o “Tell me your goals.”
o “Tell me what you heard.”
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… But There’s No Time to Waste
“Everything depends on
execution; having just a
vision is no solution.”
– Stephen Sondheim
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Questions?
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