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Testimony on the Role of Academic Affiliates in the CARES Program

Thank you for inviting me to testify before the Commission this afternoon. I am Dr. Jordan Cohen, President of the Association of American Medical Colleges. The AAMC represents the nation's 126 medical schools, some 400 major teaching hospitals and health systems - including over 70 VA medical centers -, 92 academic and scientific societies representing nearly 100,000 faculty, and the nation's medical students and residents. One hundred seven of the AAMC's member medical schools maintain formal affiliation agreements with a VA facility. These affiliations are vital to the missions of both the medical school and the VA partners. As requested, I will cover three things in my statement: the AAMC's overall impressions of the major issues facing medical school affiliations with VA facilities, the potential impact of new resident work hours regulations on the affiliations, and the potential impact of VA's shifting of care toward outpatient clinics.

Since the affiliation agreements began in 1946, the VA health care system and the affiliated medical schools have been intimately linked. This relationship, by all counts, has been mutually beneficial with VA gaining access to a higher standard of medical care than could be offered with a wholly full-time VA medical service, and with the affiliated medical schools gaining additional opportunities for medical education and research. As with any business relationship, there have been good times and bad, and both sides have had to work to maintain a healthy and productive relationship. A key to maintaining such a relationship has been communication. The AAMC has a VA-Deans Liaison Committee made up of eight medical school deans with VA affiliations. This committee meets regularly in Washington to discuss areas of concern with regard to the VA affiliation relationships. VA officials always attend a portion of the committee's meetings, and this level of interpersonal communication has made the Committee an invaluable forum to discuss and debate the major issues surrounding the affiliations. As you can imagine, the Capital Assets Realignment for Enhanced Services (CARES) program has been a frequent topic of discussion for the Committee.

You have requested the perspectives of the academic affiliates as they relate to the CARES process. As the VA goes forward with the process, it will understandably impact the affiliates because of the many facilities and faculty that are shared between the two partners. Without getting into specific examples, I think it is fair to say that there is an underlying skepticism among the medical school deans that the education and research missions of the VA are being given adequate attention in the process. While the AAMC clearly recognizes that patient care is the core mission of the VA health care system, the Association believes that the education and research missions are integral to the high-quality health care delivered by the system, and that they are critical elements in what makes the VA one of the best health care systems in the world. Additionally, given the experience of CARES in Network 12, there is some concern that the affiliates themselves are being shut out of the process and that assumptions about the affiliates' reactions are being made without appropriate consultation. While the VA leadership has been very receptive to the AAMC's concerns in this area, as the initiative expands nationwide there is still a good deal of wariness on the part of some deans.

Perhaps the most problematic issue confronting the medical school affiliates and the VA right now is that of part-time physician time and effort reporting. We have heard reports of individuals inaccurately reporting times at which they were required to be physically onsite at the VA facility. The AAMC clearly recognizes that this is a very serious problem and has stressed to our members the importance of meeting all reporting requirements. However, it is the Association's position that the current reporting system is woefully inadequate and has not kept up with the many changes that have occurred in way health care is delivered. While there are undoubtedly problems to be addressed, I believe the degree to which we are dealing with intentional fraud in this area is exceedingly small. Unfortunately, this issue has introduced some unwelcome distrust on both sides of the affiliation relationship. The AAMC is concerned that the seeming inflexibility of the core hours requirement coupled with the fear of prosecution for failure to adhere to unworkable rules has begun to impede the recruitment of needed physicians to joint or WOC appointments. This topic has been a major subject of discussions for the AAMC's VA-Deans Liaison Committee, and will be on the agenda for the spring meeting of our Council of Deans next week. We hope to work with the VA to develop a system that meets the coverage requirements of the VA health care system and the flexibility needs of the physicians.

Another area of concern relates to intellectual property. The VA Medical and Prosthetics Research program has proven over the years to be a valuable asset to both the VA and academic medicine. There are tangible benefits of research results being directly realized in the improved health care of our nation's veterans, and VA research is recognized as a world leader in areas such as spinal cord, prosthetics, geriatrics, and rehabilitation research. Additionally, by offering a dedicated funding source available only to VA employees, the program has been a vital incentive for physician scientists to accept joint appointments at the VA and the affiliated school of medicine. In the last few years, VA has sought to ensure that the products of this research provide the maximum benefit to veterans and also to re-coup some of its substantial investment by claiming ownership rights to inventions produced with VA resources. To achieve its goals, VA has asked affiliates to sign Cooperative Technology Administration Agreements (CTAAs), which set forth the terms for how to handle joint inventions with academic affiliates. While there is no question that VA is entitled to an appropriate share in the intellectual property to which it has contributed, the manner in which VA has pursued this issue has caused some consternation on the part of several deans. In particular, the VA has appeared to many as overreaching, particularly in cases concerning WOC appointed researchers. Fortunately, the positive working relationship between VA and the AAMC has provided the necessary forum for seeking a solution that both parties can support. Indeed, in recent discussions, VA leadership has expressed a willingness to allow affiliates to renegotiate their agreements if they feel the need to clarify the terms. While this issue continues to be a hot topic on our mutual agenda , progress is clearly being made.

The second question you asked me to address was how the new resident duty hours limits will affect the affiliations. There is no simple answer to that question. For most specialties, I'm quite confident that the effect will be minimal. The reason is that the vast majority of residency training programs in most disciplines currently operate well within the 80-hour weekly limit. It is the surgical specialties that are likely to impacted to the greatest extent. Indeed, speculation is widespread that some surgical subspecialties may be thinking about removing their residents from the VA in order to comply with the rules. Such a move would be most unwelcome, not only because it might require VA to contract for services at higher cost, but also because the rich training opportunities provided by the VA would be lost. To date, however, the Association has not heard of definite plans for this to occur. Another potential impact of the new duty-hour limits is on "moonlighting" at the VA. My understanding is that many VA hospitals currently offer moonlighting opportunities for residents and the new requirements may curtail some of that activitiy. Moreover, many teaching hospitals are hiring additional personnel (e.g., physicians assistants) to handle some of the workload suggesting that the VA may need to be prepared to hire more staff to deliver support services. Concerns remain about who should pay for the additional providers. Finally, it should be noted that small affiliates with low resident numbers may be harder hit than larger affiliates.

I think it is also important to mention the potential impact of other changes in the ACGME requirements. For example, the limitations on the number of patients that a given resident may be responsible for and the tightening supervision standards may require an increased level of participation amongst VA attending physicians. Adapting to these changes underscores the need for flexibility in the relationships between the VA hospital and the faculty of the affiliate medical school.

The third question I've been asked to answer relates to the effects on the affiliations of VA's move toward more outpatient care at Community-Based Outpatient Clinics (CBOCs). Obviously this issue will vary from facility to facility and from region to region across the country. For areas such as the Northeast, where the veteran rolls are declining, a smaller patient base could cause problems for some academic programs. An obvious solution would be to have residents travel to the CBOC sites; to do so, however, raises other problems, particularly regarding travel times and costs. Perhaps the greatest impact on the affiliates of the move toward outpatient services is the likely reduction of jointly-appointed VA faculty in favor of full-time VA physicians. While academic affiliates would likely be given the opportunity to contract for these services, it would bring a totally new dynamic to the relationship, as contracted services may be less economical, and contracted physicians would no longer be eligible for research funds.

There is a common saying amongst medical schools that if you've seen one medical school, you've seen one medical school. The same applies to affiliation agreements; they are all different and each has its own nuances and organizational culture. There are, however, some generalizations about the affiliations that can be stated with confidence. There is a perception amongst medical school deans that the shift of the VA health care system from a hospital-based system to an outpatient, network-based system has reduced the importance of the VA's education and research missions. At the same time, the issues that I mentioned earlier -- particularly the nature of time and effort reporting for part time VA physicians and the ownership of intellectual property deriving from joint research -- have strained the relationship between VA and the affiliate medical schools. Compounding the strain has been the requirement now for the dean to relate not just to the local VA medical director but also to the more distant the VISN director.

At this tender moment in the historic affiliation between the VA and the nation's medical schools, the AAMC would welcome a strong affirmation by both partners of the overarching benefits of a close working relationship. As the VA moves forward with the CARES initiative, it is vitally important that the your medical school partners be included in the decision making process.