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Testimony on Veterans Major Medical Facilities Construction

Good Afternoon Mr. Chairman and Members of the Subcommittee. Thank you for the opportunity to address you on this important issue. I am Donald Wilson, vice president for medical affairs, University of Maryland, and dean of the School of Medicine. Today, I am representing the Association of American Medical Colleges (AAMC). The AAMC represents the nation's 125 accredited allopathic medical schools, over 400 major teaching hospitals and health systems including 72 Veterans Affairs Medical Centers, 98 academic and scientific societies representing 105,000 faculty members and the nation's 66,000 medical student and 97,000 residents. As I am sure you know, 107 of those 125 medical schools maintain formal affiliation agreements with VA medical centers and these agreements are mutually beneficial to both the academic partner and the VA in each of the VA's three major missions of patient care, research and education.

The Subcommittee, I am sure, is familiar with the importance of the affiliation agreements to both the VA and the affiliated health professions schools. The AAMC has testified to this relationship several times over the last few years; however, those statements have most often focused on the education and patient care missions rather than research. From the standpoint of a dean of an affiliated medical school, I see the VA research program as an opportunity for collaboration, as a dedicated funding source that the faculty at my school can access, and as a tool I can use in faculty recruiting. The success rates for VA research grants are greater than those of the NIH and the natural physical proximity of the facilities lends itself to collaborative research efforts.

One of the problems that the research facilities face is the competition in the VA Minor Construction budget account for limited funds. The VA research program has seen some significant increases in recent years, but funds are statutorily prohibited from being used for construction or renovation. Even if they were able to be used, the program is still not big enough to address the critical research needs and the facilities issues. Research facility needs less than $4 million are funded through the Minor Construction line item, competing against other VA facility needs not necessarily related to research such as parking lots, elevators, air conditioners, etc. For this reason the AAMC believes that the research enterprise would be well served if the Subcommittee supported a separate funding stream that would be dedicated to upgrading and improving existing research facilities. From the affiliate standpoint, it would allow an academic institution to count on the VA facility as a potential site for state-of-the-art research. As recommended by the Friends of VA Medical Care and Health Research Coalition, such a line item would fund one-time construction or renovation projects, and be merit-reviewed based on VA's assessment of needs. The Friends of VA have recommended an appropriation of $45 million for this account in the first year.

There are many anecdotal examples of problems with research competing with other needs. One example is the air vent intake at the VA Boston Healthcare System that is located over the hospital loading dock and draws exhaust fumes into the laboratories in certain instances. It would take $300,000 to relocate the intake, but in six successive years, funding has not been available, which limits the potential research that can be conducted in this laboratory by both VA and the affiliated Harvard researchers. Another relates to a researcher who has funding lined up for a grant that requires storing tissue samples in sub-zero freezers, which are covered as a direct cost of the grant. The space has been allocated, but the researcher is unable to secure $30,000 to upgrade the electrical system to support the freezers. VA researchers in Gainesville, Florida are unable to conduct certain types of research because their "wet lab" countertops are made of particle board and formica, rather than the standard stone, and are easily burned and stained from exposure to heat and chemicals. At the Southern Arizona VA Health Care System in Tucson, one of the buildings has no elevator and patients involved in clinical research are required to climb stairs. They also spend precious resources outsourcing kennels for dogs because no funding is available to bring the existing kennels into line with AAALAC or FDA standards.

However, the main reason for my being here this afternoon is not to testify to the poor condition of VA research facilities, but rather to the value of the VA research facilities to the affiliation agreements. One of the obvious benefits is that state-of-the-art research facilities help in the recruitment of top researchers to the affiliated school and therefore, to the faculty of the VA medical center as well. In best case scenarios, top-notch research facilities help both the VA and the affiliate to leverage their research funds. For example, a partnership between the Penn State Milton S. Hershey Medical Center and School of Medicine and the Lebanon, Pennsylvania VA Medical Center recently undertook a joint project to renovate laboratory space at the Lebanon VA, which will allow researchers with joint appointments to draw down additional federal research dollars from VA and other sources. Under this agreement, the affiliate came up with 75 percent of the needed funds, but without the VA contribution, the project could not have gone forward. As a result, significant research related to regulating blood pressure in cardiac patients, and kidney failure has been able to move forward.

Another good example of the collaboration between affiliates and the VA is at the Texas A&M University System Health Science Center School of Medicine. Several years ago, they began a three way initiative with Scott and White Memorial Hospital and the Central Texas Veterans Health Care System to build a world-class Cardiovascular Research Institute in Temple, Texas. In the true spirit of partnership, these three entities have all contributed significant resources to the initiative, with the university providing the faculty salary lines, the private hospital providing substantial start-up resources, and the VA producing the building. With completion of the building expected this fall, they plan to have three major research groups in Molecular Cardiology, Vascular Biology and Hypertension occupying 35,000 square feet in the building on the VA campus. The interim dean at Texas A&M expects to begin recruiting basic and clinical scientists to the VA within the year. This initiative would not have come about without the full cooperation of the local VA medical center director and the ability to redirect some funds that were targeted for another building. However, the resulting institute provides much greater benefit than any of the partners would have been able to establish on their own.

However, not all the affiliations have such positive stories to tell. At the University of Iowa School of Medicine, about half of the 40,000 square feet of VA research space is located in an aging building that was originally constructed in the 1950s and converted to research space in the 1970s. The HVAC system is so outdated that the labs still use window air conditioners and steam radiators. Researchers are forced to work at night during summer months to avoid melting some of their lab gels and triggering heat shocks to some of their cell lines. The building has no fire sprinkler system or sensors and the Fire Marshall has recommended that the building be discontinued as a research laboratory. As if that wasn't enough, the building has no elevators and large equipment must be fork lifted or craned into the second floor. And due to the age of the building, it can only handle 200 pounds per square foot instead of the standard 600 pounds, limiting the types of instrumentation that can be brought in. All of these issues are unfortunate, but what is perhaps the most disappointing issue at the Iowa VA medical center is that the university feels it cannot in good conscience ask students or postdocs to join these labs. As a result, the university has chosen not to respond to specific program announcements from VA. By undermining the ability of individuals and institutions to leverage additional support from VA and other sources, the quality of science being conducted in the labs is being compromised. Although this extreme example may need major rather than minor construction funds to remedy the problems, the resulting decision to not pursue research funding due directly to the deteriorated state of the facility is a disturbing conclusion.

Dilapidated research facilities also hinder the recruitment process for faculty at both the VA and the affiliated medical school. The University of California, San Diego and the VA San Diego Healthcare system have been unable to recruit a top Hepatitis C specialist because the research space is lacking. Similarly, the University of Colorado Health Sciences Center and the Denver VA Medical Center have been repeatedly turned down by top cardiologists, pulmonary and gastroenterology physicians who cited poor quality research facilities as a major factor in their decisions. This inability to recruit impacts severely on the quality of care for veterans.

Within my own VA affiliation in Baltimore, we are in drastic need of about 20,000 net square feet just to meet our current research space needs. Even though the existing building was only completed in 1993, it is based on designs that took into account the level of research funding from the late 1970s. Funding had increased more than eightfold by the time construction was completed. This year, the VA Maryland Health Care System (VAMHCS) has been awarded about $12.5 million in VA research funding. Those same principal investigators have obtained additional funds from non-VA sources for a total research enterprise of $33 million. Because of a lack of space, at least 18 of those researchers are being housed in University of Maryland School of Medicine laboratories at the expense of the university. Such relationships are only possible because of the close working relationship between myself and the Baltimore VA medical center leadership.

Because of unique geographic and architectural restrictions on the Baltimore VA medical center, the most viable option is to purchase additional space that could be used jointly by the VAMHCS research program and the University of Maryland School of Medicine. In a VA central office survey, the Baltimore VA medical center ranks second nationally in terms of needed renovation with a price tag of approximately $3.5 million needed to ameliorate the current situation. However, minor construction and renovation projects like this one are forced to compete with some of the clinical needs of the VA health care system. I would not suggest that research facility needs should outweigh the needs of the clinical program, but I would suggest that a better process is needed so research facility needs are not consistently left at the bottom of the list.

The importance of the VA affiliation to the research program is not limited to facility issues. The gerontology division at the University of Maryland School of Medicine is totally housed at the VA, and our new state-of-the-art cardiovascular exercise research facility is housed at the VA even though 85 percent of it was funded by the School of Medicine. The VA will soon have a human performance laboratory to look at things such as gait analysis to help diagnose and treat patients suffering from movement disorders and stroke. Additionally, a significant proportion of the Parkinson's disease and multiple sclerosis research that goes on at the School of Medicine is located at the VA. Again, I cannot stress enough that these types of relationships are mutually beneficial to both the VA and the School of Medicine and that the ultimate benefits go to the patients. But the full impact of the potential of the relationship cannot be realized while the VA research facilities are inadequate. For the affiliation partnership to flourish, resources need to come from both partners. Currently, the biggest need on the VA side is research space and I believe that a dedicated funding source for VA research facilities that does not compete directly with clinical needs is necessary to further our shared goals.

In the first session of the 107th Congress, the House passed legislation (H.R. 811) that would have dedicated funding for VA facility construction, with a portion set aside for urgent research needs. I have also had the opportunity to briefly review H.R. 4514, the "Veterans' Major Medical Facilities Construction Act of 2002." First I would like to commend both this subcommittee and the full House VA committee for their leadership and support on this issue. Second, I would like to urge the Congress as a whole to implement a proposal that would provide a dedicated, peer-reviewed funding stream for VA research facility needs. The AAMC, as a member of the Executive Committee of the Friends of VA Medical Care and Health Research Coalition, has endorsed the approach of a separate appropriations line item that I noted earlier in my statement. Whichever approach the committee chooses to pursue, a new authorization or a new appropriations line item within the existing structure, I urge you to make sure than research is not relegated to the bottom of the pile.

In conclusion, let me state again the mutually beneficial characteristics of the VA academic affiliations. It is well documented that the affiliations improve patient care as well as the education of the next generation of our nation's health care professionals. The value of research to the affiliations, the subject of today's hearing is not as well known. My affiliation is not unique. Many affiliations are marked by departments and divisions that are housed in VA space. Many, if not most, of the VA researchers hold joint faculty appointments at the affiliated medical school. The walls between School of Medicine and VA research projects are often blurred as space, funding, and salary support usually come from multiple sources. In order for these affiliations to work with the highest possible efficiency it is necessary for the facilities in which the research is conducted to be state-of-the-art. At the same time, the patient care strains on the VA medical care budget are well documented. VA research facility needs should not be forced to compete against those clinical needs, but nor can they be ignored.

Thank you again for the opportunity to testify this afternoon.