**Appendices**

**Appendix I. List of National Performance Review Hammer Awards Received
by VHA as of March 31, 1996**

+-----------------------------------+----------------------------------+
| **Facility**                      | **Initiatives for FY 96**        |
+-----------------------------------+----------------------------------+
| CHAMPVA Center Denver, CO         | Program Innovations              |
+-----------------------------------+----------------------------------+
| VAMC Topeka, KS                   | Radio Frequency Computer System  |
|                                   | for Medication Administration    |
+-----------------------------------+----------------------------------+
| VAMCs Fort Meade/Hot Springs, SD  | Black Hills VA Alliance          |
+-----------------------------------+----------------------------------+
| VAMC Tampa, FL                    | Radiology Transportation Project |
+-----------------------------------+----------------------------------+
| VHA/VACO Washington, D.C.         | Re-engineering Design and        |
|                                   | Construction                     |
| Facilities Management             |                                  |
|                                   | Standards                        |
+-----------------------------------+----------------------------------+
| VAMC Hampton, VA                  | Reinventing Laboratory Reference |
|                                   | Testing                          |
+-----------------------------------+----------------------------------+
| VAMC Ann Arbor, MI                | Lodging Program Team             |
+-----------------------------------+----------------------------------+
| VAMC Lebanon, PA                  | Asbestos Management Team         |
+-----------------------------------+----------------------------------+
| VAMC Manchester, NH               | Reinventing Surgical Service     |
|                                   | with Focus on Same Day Surgery   |
+-----------------------------------+----------------------------------+
| OA&MM and VHA - VACO & VAMC       | Clothing for Homeless Veterans:  |
| Lyons, NJ                         |                                  |
|                                   | VA\'s Partnership Initiative     |
|                                   | with GSA and DoD                 |
+-----------------------------------+----------------------------------+
| VAMCs Milwaukee, WI/Iron          | Telepathology                    |
| Mountain, MI                      |                                  |
+-----------------------------------+----------------------------------+
| VAMC Martinsburg, WV              | VA On-Line Service               |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| **Facility**                      | **Initiatives for FY 95**        |
+-----------------------------------+----------------------------------+
| VAMC Omaha, NE                    | Fiscal Service                   |
|                                   |                                  |
|                                   | Medical Care Cost Recovery Team  |
+-----------------------------------+----------------------------------+
| VAMC Albany, NY                   | Clinical Pathway for Hip         |
|                                   | Replacement                      |
+-----------------------------------+----------------------------------+
| VAMC Louisville, KY               | Electronic Paperless Travel      |
|                                   | Management System                |
+-----------------------------------+----------------------------------+
| VAMC Tucson, AZ                   | Telephone Linked Care Team       |
+-----------------------------------+----------------------------------+
| VHA/VACO, Office of Quality       | New Customer Satisfaction Survey |
| Management, Washington D.C.       |                                  |
|                                   | Program and an Education Module  |
+-----------------------------------+----------------------------------+
| VAMC Milwaukee, WI                | Home Oxygen Quality Improvement  |
|                                   | Team                             |
+-----------------------------------+----------------------------------+
| VAMC San Antonio, TX              | Government and Private Sector    |
|                                   | Cooperation                      |
+-----------------------------------+----------------------------------+
| VAMC & VARO Houston, TX           | Construction of New              |
|                                   |                                  |
|                                   | VA Regional Office Building      |
+-----------------------------------+----------------------------------+
| Hines Service and Distribution,   | Computer Upgrade Program         |
| IL                                |                                  |
+-----------------------------------+----------------------------------+
| VHA/VACO Canteen Service,         | Food Concept Development Team    |
| Washington, D.C.                  |                                  |
+-----------------------------------+----------------------------------+
| VA Outpatient Clinic, Columbus,   | Medical Care Cost Recovery Team  |
| OH                                |                                  |
+-----------------------------------+----------------------------------+

+-----------------------------------+----------------------------------+
| **Facility**                      | **Initiatives for FY 94**        |
+-----------------------------------+----------------------------------+
| Greater New York City             | Client-Centered, Coordinated     |
|                                   | Teamwork                         |
| VA Consortium on Homeless         |                                  |
| Veterans, NY                      |                                  |
+-----------------------------------+----------------------------------+
| VAMC Batavia, NY                  | Outpatient Relocation Design     |
|                                   | Team                             |
+-----------------------------------+----------------------------------+
| VA Domiciliary, White City, OR    | Policy and Procedure             |
|                                   | Re-engineering Team              |
+-----------------------------------+----------------------------------+
| VAM&ROC Sioux Falls, SD           | Reinvention Teams                |
+-----------------------------------+----------------------------------+
| VAMC Des Moines, IA               | Clinic Clerk Team                |
+-----------------------------------+----------------------------------+
| VAMC Denver, CO                   | Consolidated Contracting         |
|                                   | Activity Team                    |
+-----------------------------------+----------------------------------+
| VAMC Pittsburgh, PA               | Acquisition and Materiel         |
|                                   | Management                       |
|                                   |                                  |
|                                   | Service Team                     |
+-----------------------------------+----------------------------------+
| VAMC Prescott, AZ                 | Voluntary Service Guest          |
|                                   | Relations Team                   |
+-----------------------------------+----------------------------------+
| VAMC Dayton, OH                   | Pharmacy/Acquisition and         |
|                                   | Materiel Management Services     |
|                                   | Team                             |
+-----------------------------------+----------------------------------+
| VAMC North Chicago, IL            | Managed Care System Development  |
|                                   | Team                             |
+-----------------------------------+----------------------------------+
| VAMC Richmond, VA                 | Geriatrics Health Care Center    |
|                                   | Team                             |
+-----------------------------------+----------------------------------+

**Appendix II. List of Scissors Awards Received by VHA as of March 31,
1996**

+---------------------+--------------+---------------------------------+
| **NOMINEE**         | **LOCATION** | **DESCRIPTION OF INITIATIVE**   |
+---------------------+--------------+---------------------------------+
| **1996**            |              |                                 |
+---------------------+--------------+---------------------------------+
| Polypharmacy Team   | Tampa, FL    | Team developed and implemented  |
|                     |              | procedures that help identify   |
|                     | VAMC         | polypharmacy practices and      |
|                     |              | facilitate correcting           |
|                     |              | medication errors. As a result, |
|                     |              | fewer veterans are admitted due |
|                     |              | to over medication. The VAMC    |
|                     |              | has saved over                  |
|                     |              |                                 |
|                     |              | \$1 million.                    |
+---------------------+--------------+---------------------------------+
| Outpatient Pharmacy | San Diego,   | Customer satisfaction increased |
| Assessment Team     | CA           | from 68 percent to 98 percent   |
|                     |              | as a result of a 50 percent     |
|                     | VAMC         | reduction in pharmacy waiting   |
|                     |              | times.                          |
+---------------------+--------------+---------------------------------+
| Prosthetic          | Palo Alto,   | Improved customer satisfaction  |
| Treatment Center    | CA           | by adding a purchasing agent to |
|                     |              | prosthetics to improve response |
|                     | VAMC         | to veterans\' inquiries.        |
+---------------------+--------------+---------------------------------+
| Patient Centered    | Shreveport,  | Employees, including medical    |
| Parking Team        | LA           | staff and service chiefs, gave  |
|                     |              | up parking spaces adjacent to   |
|                     | VAMC         | the front of the medical center |
|                     |              | to assure patient access to     |
|                     |              | convenient parking.             |
+---------------------+--------------+---------------------------------+
| Ms. Patricia        | Huntington,  | Money-saving suggestion in      |
| Thacker             | WV VAMC      | patient care.                   |
+---------------------+--------------+---------------------------------+
| Ms. Debbie Jackson  | Washington,  | Innovative transportation for   |
|                     | DC VAMC      | work-therapy patients.          |
+---------------------+--------------+---------------------------------+
| Pre-Admission Team  | Lebanon, PA  | Scheduled hospital admissions   |
|                     |              | are processed over the          |
|                     | VAMC         | telephone, allowing the veteran |
|                     |              | to by-pass admissions and go    |
|                     |              | straight to the ward. Customers |
|                     |              | are happier and admission staff |
|                     |              | is able to focus on unscheduled |
|                     |              | admissions.                     |
+---------------------+--------------+---------------------------------+
|                     |              |                                 |
+---------------------+--------------+---------------------------------+
| **1995**            |              |                                 |
+---------------------+--------------+---------------------------------+
| OA&MM - VHA Task    | Washington,  | VA and the State Veterans Homes |
| Force               | D.C. VACO    | (SVH) are developing business   |
|                     |              | relationships and VA has        |
|                     |              | authorized approximately 80 SVH |
|                     |              | to use federal government       |
|                     |              | sources of supply.              |
+---------------------+--------------+---------------------------------+
| Spinal Cord Injury  | Cleveland,   | Developed training program and  |
| Team                | OH VAMC      | guidelines to expedite          |
|                     |              | processing time for spinal cord |
|                     |              | injury claims.                  |
+---------------------+--------------+---------------------------------+
| Ms. Rebecca Brown   | Minneapolis, | Revamped existing transfer and  |
|                     | MN           | referral policies.              |
|                     |              |                                 |
|                     | VAMC         |                                 |
+---------------------+--------------+---------------------------------+

+---------------------+--------------+---------------------------------+
| Human Resources     | Sepulveda,   | Implemented "One-Stop Clearance |
| Management Service  | CA           | Shop," which allows an employee |
|                     |              | who is separating from VA to    |
|                     | VAOPC        | take their clearance form to    |
|                     |              | one central location, paring a  |
|                     |              | two-hour process to only 10 or  |
|                     |              | 15 minutes.                     |
+---------------------+--------------+---------------------------------+
| Office of Executive | Washington,  | Used office automation          |
| Correspondence      | DC           | capabilities to facilitate      |
|                     |              | correcting letters instead of   |
|                     | VACO         | returning them for correction;  |
|                     |              | lowered signature levels        |
|                     |              | consistent with executive       |
|                     |              | accountability.                 |
+---------------------+--------------+---------------------------------+
| Project Management  | Washington,  | Implemented an improved and     |
| Team                | DC           | streamlined project delivery    |
|                     |              | process for major construction, |
|                     | VACO         | cutting as much as two years    |
|                     |              | off overall time-frame.         |
+---------------------+--------------+---------------------------------+
| Environmental       | Washington,  | Streamlined VA's laundry        |
| Management Service  | DC           | operations through a            |
|                     |              | centralized integration and     |
|                     | VACO         | modernization program, saving   |
|                     |              | millions of dollars.            |
+---------------------+--------------+---------------------------------+
| Mr. Melvin Sharer   | Altoona, PA  | Developed procedures to use     |
|                     |              | DHCP for reporting results from |
|                     | VAMC         | echocardiography studies.       |
+---------------------+--------------+---------------------------------+
| VA Denver           | Lakewood, CO | Conceptualized, designed,       |
| Distribution Center |              | developed and field tested a    |
| (DDC)               |              | major remote access system.     |
+---------------------+--------------+---------------------------------+
| VA On-line Project  | Martinsburg, | Implemented a 'round the clock  |
| Team                | WV           | on-line system (PC-based        |
|                     |              | technology) to allow veterans,  |
|                     |              | veteran organizations or any    |
|                     |              | interested members of the       |
|                     |              | public anywhere in the world to |
|                     |              | access information relevant to  |
|                     |              | veterans.                       |
+---------------------+--------------+---------------------------------+
| Standards Service   | Washington,  | Designed a Proactive Claims     |
|                     | DC           | Analysis and Tracking System.   |
|                     |              | This system identifies          |
|                     | VACO         | recurring construction problems |
|                     |              | that result in change orders,   |
|                     |              | claims and delays.              |
+---------------------+--------------+---------------------------------+
| Suggestion Process  | Albany, NY   | Automated system for Human      |
| Improvement Team    |              | Resources to track suggestions  |
|                     | VAMC         | in a more efficient manner.     |
+---------------------+--------------+---------------------------------+
| Ms. Patricia L.     | Huntington,  | Suggested that form bed wedges  |
| Thacker             | WV           | be issued to ambulatory         |
|                     |              | patients in need of elevation   |
|                     | VAMC         | of the head and feet during     |
|                     |              | sleep instead of electric       |
|                     |              | hospital beds.                  |
+---------------------+--------------+---------------------------------+
| Acquisition &       | Denver, CO   | Awarded a desktop delivery      |
| Materiel Management |              | office supply contract to a     |
| Service             | VAMC         | minority-owned firm. The        |
|                     |              | contract allows using services  |
|                     |              | to place their own orders via   |
|                     |              | telephone or fax against a line |
|                     |              | of credit established by the    |
|                     |              | service director.               |
+---------------------+--------------+---------------------------------+
| Asbestos Management | Lebanon, PA  | Avoided \$314,000 to date by    |
| Team                |              | re-engineering contract versus  |
|                     | VAMC         | in-house services of their      |
|                     |              | asbestos program. (Prior Hammer |
|                     |              | winner.)                        |
+---------------------+--------------+---------------------------------+
| Acquisition &       | M            | Implemented a prime vendor      |
| Materiel Management | urfreesboro, | contract for Nashville and      |
| Service             | TN           | Murfreesboro. Purchase cards    |
|                     |              | are used throughout the         |
|                     | VAMC         | centers, which streamlines      |
|                     |              | acquisition. Receipt signatures |
|                     |              | for supplies are eliminated;    |
|                     |              | equipment is bar-coded.         |
+---------------------+--------------+---------------------------------+
| Mr. David Armstrong | Washington,  | Cut travel costs associated     |
|                     | DC           | with built-in hospital          |
|                     |              | equipment inspections. A manual |
|                     | VACO         | was developed that provides     |
|                     |              | guidance for field facilities   |
|                     |              | to do inspection themselves.    |
+---------------------+--------------+---------------------------------+
| Envi                | Washington,  | Streamlined project delivery by |
| ronmental/Landscape | DC           | consolidating project           |
| Architectural       |              | development responsibility,     |
| Professional Group  | VACO         | abolishing the Environmental    |
|                     |              | Review Board (ERB), and         |
|                     |              | improving customer support.     |
+---------------------+--------------+---------------------------------+
| CHAMPVA Center      | Denver, CO   | Improved program efficiency     |
|                     |              | through paperwork reduction.    |
|                     |              | For example, revised claim form |
|                     |              | from four pages to a single     |
|                     |              | sheet; established a dedicated  |
|                     |              | phone line for care providers;  |
|                     |              | and answer Congressional        |
|                     |              | inquiries by telephone.         |
+---------------------+--------------+---------------------------------+
| Mr. James F.        | Dublin, GA   | Instituted a program of making  |
| Trusley III         |              | administrative rounds           |
|                     | VAMC         | accompanied by a                |
|                     |              | multi-disciplinary group of     |
|                     |              | clinical and administrative     |
|                     |              | program chiefs. Customer        |
|                     |              | satisfaction is up and problems |
|                     |              | are resolved quicker.           |
+---------------------+--------------+---------------------------------+
| Ms. Nancy Royce     | Louisville,  | Founded the greenhouse program  |
|                     | KY           | that enables outpatients and    |
|                     |              | inpatients to participate in    |
|                     | VAMC         | growing, planting and selling   |
|                     |              | plants.                         |
+---------------------+--------------+---------------------------------+
| VHA Canteen Service | Washington,  | Replaced old Canteens that used |
|                     | D.C.         | to offer few choices of         |
|                     |              | marginal quality and service    |
|                     | VACO         | with modern food courts         |
|                     |              | regulated with strict franchise |
|                     |              | quality standards.              |
+---------------------+--------------+---------------------------------+
| Inpatient Pharmacy  | Montgomery,  | Team has cut paper use from     |
| Paper Reduction     | AL           | four to two cases per month,    |
| Team                |              | saving \$720 per year.          |
|                     | VAMC         |                                 |
+---------------------+--------------+---------------------------------+
| Colmery-O'Neil VA   | Topeka, KS   | Developed a point of care radio |
| Medical Center      |              | frequency computer system that  |
|                     |              | has been successful in          |
|                     |              | eliminating medication          |
|                     |              | administration errors.          |
+---------------------+--------------+---------------------------------+
| Pharmacy Service    | F            | Improved pharmacy procedures    |
|                     | ayetteville, | reduced the waiting time for    |
|                     | AR           | prescriptions to 10 minutes. A  |
|                     |              | pharmacy reorganization allows  |
|                     | VAMC         | sharing of bulk stock           |
|                     |              | medications, thus reducing the  |
|                     |              | size of the pharmacy inventory. |
+---------------------+--------------+---------------------------------+
| Pharmacy Service    | Jackson, MS  | Redesigned areas for            |
|                     |              | centralized order entry,        |
|                     | VAMC         | improved response time and      |
|                     |              | improved verification process.  |
+---------------------+--------------+---------------------------------+

+---------------------+--------------+---------------------------------+
| Pharmacy Team       | Los Angeles, | Reduced prescription fill time  |
|                     | CA           | from 30 minutes to between 10   |
|                     |              | and 15 minutes.                 |
|                     | VAOPC        |                                 |
+---------------------+--------------+---------------------------------+
| Coordination        | Loma Linda,  | Identified areas for            |
| Between Inpatient   | CA           | improvement in the patient      |
| And Outpatient      |              | medication profile, resulting   |
| Medication Team     | VAMC         | an average savings of \$48.40   |
|                     |              | per patient discharge, or       |
|                     |              | \$174,240 per year.             |
+---------------------+--------------+---------------------------------+
| Blood Usage         | Loma Linda,  | Ordered pre-op blood and blood  |
| Committee           | CA           | products in a timely manner.    |
|                     |              |                                 |
|                     | VAMC         |                                 |
+---------------------+--------------+---------------------------------+
| VAMC Allen Park     | Allen Park,  | Implemented primary care.       |
|                     | MI           |                                 |
+---------------------+--------------+---------------------------------+
| South Texas         | Kerrville,   | Implemented primary care        |
| Veterans Healthcare | TX           | program that reduced waiting    |
| System - Kerrville  |              | time by 50 percent reduction    |
| Division            |              | and shifted treatment focus     |
|                     |              | from inpatient to less costly   |
|                     |              | outpatient care for less acute  |
|                     |              | problems.                       |
+---------------------+--------------+---------------------------------+
| Primary Care Team   | Mountain     | Since moving to primary care,   |
|                     | Home, TN     | the team cut waiting time to 20 |
|                     | VAMC         | minutes. Telephone liaison      |
|                     |              | allows patients to schedule or  |
|                     |              | change appointments, receive    |
|                     |              | test results and seek medical   |
|                     |              | advice. VAMC has also been      |
|                     |              | aggressively contracting for    |
|                     |              | services in the community.      |
+---------------------+--------------+---------------------------------+
| Primary Care Staff  | F            | Primary care program provides   |
|                     | ayetteville, | outpatient treatment in lieu of |
|                     | AR           | inpatient care as appropriate.  |
|                     |              |                                 |
|                     | VAMC         |                                 |
+---------------------+--------------+---------------------------------+
| Endocrine &         | Iowa City,   | New specialized clinic          |
| Diabetes Clinic     | IA           | addresses issues of diabetic    |
| Team                |              | patients and others.            |
|                     | VAMC         |                                 |
+---------------------+--------------+---------------------------------+
| Patient & Family    | Loma Linda,  | Individuals from different      |
| Education Umbrella  | CA           | health disciplines worked to    |
| Body                |              | improve the quality of patient  |
|                     | VAMC         | and family education.           |
+---------------------+--------------+---------------------------------+
| Short Stay Team     | Mountain     | VAMC created a short stay unit  |
|                     | Home, TN     | and cut costs by converting a   |
|                     | VAMC         | 40-bed seven-day-a-week ward to |
|                     |              | a 15 bed unit open five days a  |
|                     |              | week. VAMC used a patient call  |
|                     |              | back program to get feedback to |
|                     |              | continuously improve service,   |
|                     |              | and implemented a               |
|                     |              | pre-admissions clinic.          |
+---------------------+--------------+---------------------------------+
| Spinal Cord Injury  | Richmond, VA | Average length of stay and      |
| Service             |              | costs for hospitalization in    |
|                     | VAMC         | SCI have been reduced.          |
+---------------------+--------------+---------------------------------+
| Surgical Service    | Spokane, WA  | Provided Same Day Surgery       |
|                     |              | Program and saved 61 inpatient  |
|                     | VAMC         | days.                           |
+---------------------+--------------+---------------------------------+
| Mr. Chuck Decoste   | Denver, CO   | Re-engineered the Foreign       |
| and                 | Health       | Medical Program, transferred to |
|                     | Ad           | Denver from VAMC Washington,    |
| Mr. Ken Ruyle       | ministration | D.C. Reduced resources needed   |
|                     | Center &     | to operate the program, reduced |
|                     | Tuscaloosa,  | process steps and improved      |
|                     | AL VAMC      | service to veterans.            |
+---------------------+--------------+---------------------------------+
| Standards Service   | Washington,  | Streamlined VA design and       |
|                     | DC           | construction standards by       |
|                     |              | reducing mandatory              |
|                     | VACO         | requirements, putting design    |
|                     |              | manuals "on-line," benchmarking |
|                     |              | against industry norms and      |
|                     |              | eliminating half of current     |
|                     |              | policy statements.              |
+---------------------+--------------+---------------------------------+
| Dorothy Fish,       | Asheville,   | Construction of a new 120 bed   |
| Barbara Bell, Diana | NC           | NHCU to save money and design   |
| Carranza            |              | innovations to enhance patient  |
|                     | VAMC         | care environment.               |
+---------------------+--------------+---------------------------------+
| Physical Therapy    | Minneapolis, | Initiated week-end tour of duty |
| Section             | MN           | for therapy without disrupting  |
|                     |              | treatment in schedules for      |
|                     | VAMC         | patients during the week.       |
+---------------------+--------------+---------------------------------+
| Stratton VA Medical | Albany, NY   | Obtained \$500,000 for a Fisher |
| Center              |              | House for veterans and their    |
|                     |              | families. Significant customer  |
|                     |              | service initiative.             |
+---------------------+--------------+---------------------------------+
| MCCR Copay Unit     | Chicago, IL  | Created "one-step shopping" for |
|                     |              | services and decreased patient  |
|                     |              | waiting time.                   |
+---------------------+--------------+---------------------------------+
| Mr. J. R. Alford    | Huntington,  | Established a "help desk" to    |
|                     | WV           | assist veterans and their       |
|                     |              | families obtain directions,     |
|                     | VAMC         | information about service       |
|                     |              | availability, appointment       |
|                     |              | scheduling, patient locations   |
|                     |              | and special programs.           |
+---------------------+--------------+---------------------------------+
| Ms. Deann Hufnagle, | Minneapolis, | Recorded teaching booklets for  |
| LPN                 | MN           | the visually impaired and       |
|                     |              | illiterate and semi-literate    |
|                     | VACO         | patients.                       |
+---------------------+--------------+---------------------------------+
| Ms. Patti Maddox    | Oklahoma     | Reduced the time involved in    |
|                     | City, OK     | sending VACO patient packets    |
|                     |              | for kidney and liver            |
|                     | VACO         | transplants. Improved customer  |
|                     |              | service by providing a specific |
|                     |              | person as a point of contact    |
|                     |              | for veterans being evaluated    |
|                     |              | for transplants.                |
+---------------------+--------------+---------------------------------+
| Parking Veterans    | Pittsburgh,  | Implemented "valet" type        |
| First Team          | PA           | parking for veterans, their     |
|                     |              | families and friends at the     |
|                     | VAMC (UD)    | Oakland acute care division of  |
|                     |              | the Pittsburgh VAMC.            |
+---------------------+--------------+---------------------------------+
| Telephone Linked    | Tucson, AZ   | Telephone linked care services  |
| Care Team           |              | has improved care for patients  |
|                     | VAMC         | and reduced visits required to  |
|                     |              | obtain care from more than 100  |
|                     |              | to an average of 60 to 80; 125  |
|                     |              | telephone visits are made per   |
|                     |              | day.                            |
+---------------------+--------------+---------------------------------+
| Hospice Team        | Tucson, AZ   | Identify patients who might     |
|                     |              | benefit from the hospice        |
|                     | VAMC         | program.                        |
+---------------------+--------------+---------------------------------+
| 10-10 Team          | Washington,  | Team reduced the infamous 10-10 |
|                     | DC           | form from eight pages and       |
|                     |              | almost 200 questions requiring  |
|                     | VACO         | 80 minutes to complete to a     |
|                     |              | single page.                    |
+---------------------+--------------+---------------------------------+
| VA Medical Center   | Marion, IL   | Reduced waiting time to see     |
|                     |              | doctor (from as long as all day |
|                     |              | to 15 minutes) by shifting      |
|                     |              | workloads, realigning services  |
|                     |              | and realigning staff.           |
+---------------------+--------------+---------------------------------+

+---------------------+--------------+---------------------------------+
| Medical Walk-In     | Richmond, VA | Significantly re-engineered     |
| Process Action Team |              | processes to reduce waiting     |
|                     | VAMC         | times, enhance space            |
|                     |              | utilization and improve         |
|                     |              | customer service.               |
+---------------------+--------------+---------------------------------+
| Mental Hygiene      | Erie, PA     | Reduce waiting times from one   |
| Clinic Treatment    |              | month to one or two days for    |
| Team                | VAMC         | initial appointments for mental |
|                     |              | health services. Cut costs by   |
|                     |              | shifting initial appointments   |
|                     |              | from the psychiatric staff to   |
|                     |              | the social work staff without   |
|                     |              | compromising quality of care.   |
+---------------------+--------------+---------------------------------+
| Nuclear Medicine    | Erie, PA     | Working with the Cleveland      |
| Task Force          |              | VAMC, this task force cut       |
|                     | VAMC         | turn-around time for exam       |
|                     |              | results from as long as 12      |
|                     |              | weeks to five days while saving |
|                     |              | about \$15,000 per year.        |
+---------------------+--------------+---------------------------------+
| Dr. Norman Flaxman  | Little Rock, | Eliminated dental exams for     |
| and                 | AR           | ward patients and increased the |
|                     |              | amount of available "chair"     |
| Dr. Eugene Towbin   | VAMC         | time. Decreased waiting time    |
|                     |              | for appointments by             |
|                     |              | approximately one day per week. |
|                     |              | Waiting times for follow-up     |
|                     |              | care were reduced from four to  |
|                     |              | two months.                     |
+---------------------+--------------+---------------------------------+
| Dental ER Team      | Northport,   | Significantly decreased the     |
|                     | NY           | waiting times of veterans       |
|                     |              | coming to the ER for dental     |
|                     | VAMC         | treatment by streamlining and   |
|                     |              | changing the patient routing    |
|                     |              | process.                        |
+---------------------+--------------+---------------------------------+
| Standards Service   | Washington,  | Improved and streamlined the    |
|                     | DC           | development, maintenance, and   |
|                     |              | distribution of design and      |
|                     | VACO         | construction standards.         |
+---------------------+--------------+---------------------------------+

Appendix III. Listing of the Strategic Healthcare Groups

+-----------------------------------+----------------------------------+
| **Strategic Healthcare Groups**   | **Specialty Areas Included**     |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Primary and Ambulatory Care       | Primary Care, Optometry,         |
|                                   | Ophthalmology, Podiatry, Spinal  |
|                                   | Cord Injury, Dentistry           |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Mental Health and Behavioral      | Psychiatry, Psychology,          |
| Services                          | Readjustment Counseling\*        |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Geriatrics and Extended Care      | Geriatrics, Gerontology          |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Acute Care Hospital-Based         | Medicine and Medical             |
| Services                          | Subspecialties, Surgery and      |
|                                   | Surgical Subspecialties,         |
|                                   | Neurology, Anesthesiology        |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Diagnostic Services               | Radiology, Nuclear Medicine,     |
|                                   | Anatomic and Clinical Pathology  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Pharmacy Service                  | Pharmacy                         |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Prosthetics and Sensory Aids      | Prosthetics, Sensory Aids        |
| Service                           |                                  |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Rehabilitation Services           | Physical Medicine and            |
|                                   | Rehabilitation,                  |
|                                   |                                  |
|                                   | Blind Rehabilitation, Recreation |
|                                   | Therapy and Audiology and Speech |
|                                   | Pathology                        |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Nursing Services                  | Nursing                          |
+-----------------------------------+----------------------------------+
|                                   |                                  |
+-----------------------------------+----------------------------------+
| Allied Clinical Services          | Nutrition and Food Service,      |
|                                   | Chaplain, Social Work            |
+-----------------------------------+----------------------------------+

\* Although administratively separate, the Readjustment Counseling
Service will be clinically aligned with this SHG.-

Appendix IV. VA-Medical School Affiliations as of March 31, 1996

**Health Professions Education Program**

Title 38 U.S.C. mandates that VA assist in the training of health
professionals for its own needs and for those of the nation. Each year,
over 100,000 health science students receive some or all of their
clinical training in VA facilities through affiliations with over 1,000
educational institutions. Currently, 130 VA medical facilities are
affiliated with 105 of the nation\'s medical schools. More than 34,000
medical residents and 21,000 medical students receive some of their
training in VHA facilities every year. VHA is also affiliated with many
of the nation\'s schools of dentistry, optometry and podiatry and
supports residencies in these professions. Together these activities
directly support the patient care mission of VA and assist in training
health manpower for the nation and in recruitment and retention of VHA
medical staff.

VHA also contributes significantly to education and training in more
than 40 associated health professions. Each year, an average of 54,000
students at the graduate and undergraduate level receive all or part of
their clinical experience at VHA facilities. The great majority of
associated health students (95 percent) participate on a without
compensation (WOC) basis. VHA provides funding support to over 2,500
advanced trainees who contributed to patient care during their training
in 29 program areas such as Audiology/Speech Pathology, Blind
Rehabilitation, Dietetics, Nursing, Occupational Therapy, Pharmacy,
Psychology, and Social Work. Affiliated education programs also include
areas of specific importance to VHA such as primary care, substance
abuse, PTSD, geriatrics, interdisciplinary team training and research.

+-------------------+-----+--------------------------------------------+
| **FACILITY**      | **S | **AFFILIATED WITH SCHOOL(S) OF MEDICINE**  |
|                   | TAT |                                            |
|                   | E** |                                            |
+-------------------+-----+--------------------------------------------+
| ALBANY            | NY  | Albany Medical College                     |
+-------------------+-----+--------------------------------------------+
| ALBUQUERQUE       | NM  | University of New Mexico                   |
+-------------------+-----+--------------------------------------------+
| ALEXANDRIA        | LA  | Tulane University                          |
+-------------------+-----+--------------------------------------------+
| ALLEN PARK        | MI  | Wayne State University                     |
+-------------------+-----+--------------------------------------------+
| ALTOONA           | PA  | Conemaugh Valley Memorial Hospital         |
+-------------------+-----+--------------------------------------------+
| AMARILLO          | TX  | Texas Tech University                      |
+-------------------+-----+--------------------------------------------+
| ANN ARBOR         | MI  | University of Michigan                     |
+-------------------+-----+--------------------------------------------+
| ASHEVILLE         | NC  | Duke University                            |
+-------------------+-----+--------------------------------------------+
| ATLANTA           | GA  | Emory University                           |
+-------------------+-----+--------------------------------------------+
| AUGUSTA           | GA  | Medical College of Georgia                 |
+-------------------+-----+--------------------------------------------+
| BALTIMORE         | MD  | University of Maryland-Baltimore; Johns    |
|                   |     | Hopkins University                         |
+-------------------+-----+--------------------------------------------+
| BATAVIA           | NY  | University of Rochester                    |
+-------------------+-----+--------------------------------------------+
| BATTLE CREEK      | MI  | Michigan State University                  |
+-------------------+-----+--------------------------------------------+
| BAY PINES         | FL  | University of South Florida                |
+-------------------+-----+--------------------------------------------+
| BECKLEY           | WV  | West Virginia School of Osteopathic        |
|                   |     | Medicine                                   |
+-------------------+-----+--------------------------------------------+
| BEDFORD           | MA  | Boston University                          |
+-------------------+-----+--------------------------------------------+
| BIG SPRING        | TX  | Texas Tech University                      |
+-------------------+-----+--------------------------------------------+
| BILOXI            | MS  | Louisiana State University - New Orleans;  |
|                   |     | Tulane University                          |
+-------------------+-----+--------------------------------------------+
| BIRMINGHAM        | AL  | University of Alabama                      |
+-------------------+-----+--------------------------------------------+
| BOISE             | ID  | University of Washington                   |
+-------------------+-----+--------------------------------------------+
| BONHAM            | TX  | Texas Collage of Osteopathic Medicine      |
+-------------------+-----+--------------------------------------------+
| BOSTON            | MA  | Boston University; Tufts University        |
+-------------------+-----+--------------------------------------------+
| BROCKTON          | MA  | Harvard Medicine School; Tufts University  |
+-------------------+-----+--------------------------------------------+
| BRONX             | NY  | Mt. Sinai School of Medicine               |
+-------------------+-----+--------------------------------------------+
| BROOKLYN          | NY  | SUNY Health Science Center-Brooklyn        |
+-------------------+-----+--------------------------------------------+
| BUFFALO           | NY  | SUNY at Buffalo                            |
+-------------------+-----+--------------------------------------------+
| CANANDAIGUA       | NY  | University of Rochester                    |
+-------------------+-----+--------------------------------------------+
| CASTLE POINT      | NY  | New Rochelle Hospital Medical Center       |
+-------------------+-----+--------------------------------------------+
| CHARLESTON        | SC  | Medicine University of South Carolina      |
+-------------------+-----+--------------------------------------------+
| CHEYENNE          | WY  | Family Practice Residency Program at       |
|                   |     | Cheyenne                                   |
+-------------------+-----+--------------------------------------------+
| CHICAGO LS        | IL  | Northwestern University Medicine School    |
+-------------------+-----+--------------------------------------------+
| CHICAGO WS        | IL  | University of Illinois College of Medicine |
+-------------------+-----+--------------------------------------------+
| CHILLICOTHE       | OH  | Ohio State University                      |
+-------------------+-----+--------------------------------------------+
| CINCINNATI        | OH  | University of Cincinnati                   |
+-------------------+-----+--------------------------------------------+
| CLARKSBURG        | WV  | West Virginia University                   |
+-------------------+-----+--------------------------------------------+
| CLEVELAND         | OH  | Case Western Reserve University            |
+-------------------+-----+--------------------------------------------+
| COATESVILLE       | PA  | Temple University Medicine School          |
+-------------------+-----+--------------------------------------------+
| COLUMBIA-MO       | MO  | University of Missouri-Columbia            |
+-------------------+-----+--------------------------------------------+
| COLUMBIA-SC       | SC  | University of South Carolina               |
+-------------------+-----+--------------------------------------------+
| COLUMBUS          | OH  | Ohio State University                      |
+-------------------+-----+--------------------------------------------+
| DALLAS            | TX  | University of Texas Health Sciences        |
|                   |     | Center-Dallas                              |
+-------------------+-----+--------------------------------------------+
| DANVILLE          | IL  | University of Illinois - Urbana            |
+-------------------+-----+--------------------------------------------+
| DAYTON            | OH  | Wright State University                    |
+-------------------+-----+--------------------------------------------+
| DENVER            | CO  | University of Colorado                     |
+-------------------+-----+--------------------------------------------+
| DES MOINES        | IA  | University of Iowa                         |
+-------------------+-----+--------------------------------------------+
| DUBLIN            | GA  | Mercer University College of Medicine      |
+-------------------+-----+--------------------------------------------+
| DURHAM            | NC  | Duke University                            |
+-------------------+-----+--------------------------------------------+
| EAST ORANGE       | NJ  | University of Medicine and Dentistry of    |
|                   |     | New Jersey-Newark                          |
+-------------------+-----+--------------------------------------------+
| EL PASO           | TX  | Texas Tech University                      |
+-------------------+-----+--------------------------------------------+
| FARGO             | ND  | University of North Dakota                 |
+-------------------+-----+--------------------------------------------+
| FAYETTEVILLE      | AR  | University of Arkansas for Medical         |
|                   |     | Sciences Area Health Education Center      |
|                   |     | Program                                    |
+-------------------+-----+--------------------------------------------+
| FAYETTEVILLE      | NC  | Duke University                            |
+-------------------+-----+--------------------------------------------+
| FORT HARRISON     | MT  | University of Utah                         |
+-------------------+-----+--------------------------------------------+
| FORT WAYNE        | IN  | Medical College of Toledo, Fort Wayne      |
|                   |     | Medicine Education Program                 |
+-------------------+-----+--------------------------------------------+
| FRESNO            | CA  | University of California - San Francisco   |
+-------------------+-----+--------------------------------------------+
| GAINESVILLE       | FL  | University of Florida                      |
+-------------------+-----+--------------------------------------------+
| GRAND JUNCTION    | CO  | St. Mary's Hospital and Medical Center     |
|                   |     | Program                                    |
+-------------------+-----+--------------------------------------------+
| HAMPTON           | VA  | Eastern VA Medical Authority               |
+-------------------+-----+--------------------------------------------+
| HINES             | IL  | Loyola University; University of Health    |
|                   |     | Sciences - Chicago;                        |
|                   |     |                                            |
|                   |     | University of Illinois - Urbana            |
+-------------------+-----+--------------------------------------------+
| HONOLULU          | HI  | University of Hawaii                       |
+-------------------+-----+--------------------------------------------+
| HOUSTON           | TX  | Baylor College of Medicine                 |
+-------------------+-----+--------------------------------------------+
| HUNTINGTON        | WV  | Marshall University                        |
+-------------------+-----+--------------------------------------------+
| INDIANAPOLIS      | IN  | Indiana University, Indianapolis           |
+-------------------+-----+--------------------------------------------+
| IOWA CITY         | IA  | University of Iowa                         |
+-------------------+-----+--------------------------------------------+
| JACKSON           | MS  | University of Mississippi Medical Center   |
+-------------------+-----+--------------------------------------------+
| KANSAS CITY       | MO  | University of Kansas                       |
+-------------------+-----+--------------------------------------------+
| LAKE CITY         | FL  | University of Florida College of Medicine  |
+-------------------+-----+--------------------------------------------+
| LAS VEGAS         | NV  | University of Nevada                       |
+-------------------+-----+--------------------------------------------+
| LEAVENWORTH       | KS  | University of Kansas Medical Center        |
+-------------------+-----+--------------------------------------------+
| LEBANON           | PA  | Pennsylvania State University              |
+-------------------+-----+--------------------------------------------+
| LEXINGTON         | KY  | University of Kentucky                     |
+-------------------+-----+--------------------------------------------+
| LINCOLN           | NE  | Creighton University; University of        |
|                   |     | Nebraska Medical Center                    |
+-------------------+-----+--------------------------------------------+
| LITTLE ROCK       | AR  | University of Arkansas for Medical         |
|                   |     | Sciences Area Health Education Center      |
+-------------------+-----+--------------------------------------------+
| LIVERMORE         | CA  | Stanford University                        |
+-------------------+-----+--------------------------------------------+
| LOMA LINDA        | CA  | Loma Linda University                      |
+-------------------+-----+--------------------------------------------+
| LONG BEACH        | CA  | University of California - Irvine          |
+-------------------+-----+--------------------------------------------+
| LOS ANGELES OPC   | CA  | University of California -Los Angeles;     |
|                   |     | University of Southern California          |
+-------------------+-----+--------------------------------------------+
| LOUISVILLE        | KY  | University of Louisville                   |
+-------------------+-----+--------------------------------------------+
| LYONS             | NJ  | University of Medicine and Dentistry of    |
|                   |     | New Jersey-Piscataway                      |
+-------------------+-----+--------------------------------------------+
| MADISON           | WI  | University of Wisconsin - Madison          |
+-------------------+-----+--------------------------------------------+
| MANCHESTER        | NH  | Harvard University                         |
+-------------------+-----+--------------------------------------------+
| MARION-IL         | IL  | Southern Illinois University               |
+-------------------+-----+--------------------------------------------+
| MARTINSBURG       | WV  | West Virginia University                   |
+-------------------+-----+--------------------------------------------+
| MEMPHIS           | TN  | University of Tennessee - Memphis          |
+-------------------+-----+--------------------------------------------+
| MIAMI             | FL  | University of Miami                        |
+-------------------+-----+--------------------------------------------+
| MILWAUKEE         | WI  | Medical College of Wisconsin               |
+-------------------+-----+--------------------------------------------+
| MINNEAPOLIS       | MN  | University of Minnesota                    |
+-------------------+-----+--------------------------------------------+
| MONTGOMERY        | AL  | University of Alabama                      |
+-------------------+-----+--------------------------------------------+
| MONTROSE          | NY  | Mt. Sinai School of Medicine; New York     |
|                   |     | Medical College                            |
+-------------------+-----+--------------------------------------------+
| MOUNTAIN HOME     | TN  | East Tennessee State University            |
+-------------------+-----+--------------------------------------------+
| MURFREESBORO      | TN  | Meharry Medical College                    |
+-------------------+-----+--------------------------------------------+
| MUSKOGEE          | OK  | University of Oklahoma Health Science      |
|                   |     | Center                                     |
+-------------------+-----+--------------------------------------------+
| NASHVILLE         | TN  | Vanderbilt University                      |
+-------------------+-----+--------------------------------------------+
| NO. CALIFORNIA    | CA  | University of California - Davis           |
| SYSTEM OF CLINICS |     |                                            |
+-------------------+-----+--------------------------------------------+
| NEW ORLEANS       | LA  | Louisiana State University; Tulane         |
|                   |     | University                                 |
+-------------------+-----+--------------------------------------------+
| NEW YORK          | NY  | New York University                        |
+-------------------+-----+--------------------------------------------+
| NEWINGTON         | CT  | University of Connecticut School of        |
|                   |     | Medicine                                   |
+-------------------+-----+--------------------------------------------+
| NORTH CHICAGO     | IL  | University of Health Sciences - Chicago    |
+-------------------+-----+--------------------------------------------+
| NORTHPORT         | NY  | SUNY at Stony Brook                        |
+-------------------+-----+--------------------------------------------+
| OKLAHOMA CITY     | OK  | University of Oklahoma Health Science      |
|                   |     | Center                                     |
+-------------------+-----+--------------------------------------------+
| OMAHA             | NE  | Creighton University; University of        |
|                   |     | Nebraska Medical Center                    |
+-------------------+-----+--------------------------------------------+
| PALO ALTO         | CA  | Stanford University                        |
+-------------------+-----+--------------------------------------------+
| PERRY POINT       | MD  | University of Maryland - Baltimore; Johns  |
|                   |     | Hopkins University                         |
+-------------------+-----+--------------------------------------------+
| PHILADELPHIA      | PA  | Medical Collage of Pennsylvania;           |
|                   |     | University of Pennsylvania                 |
+-------------------+-----+--------------------------------------------+
| PHOENIX           | AZ  | University of Arizona                      |
+-------------------+-----+--------------------------------------------+
| PITTSBURGH (HD)   | PA  | University of Pittsburgh                   |
+-------------------+-----+--------------------------------------------+
| PITTSBURGH (UD)   | PA  | University of Pittsburgh                   |
+-------------------+-----+--------------------------------------------+
| PORTLAND          | OR  | University of Oregon Health Science Center |
+-------------------+-----+--------------------------------------------+
| PROVIDENCE        | RI  | Brown University                           |
+-------------------+-----+--------------------------------------------+
| RENO              | NV  | University of Nevada                       |
+-------------------+-----+--------------------------------------------+
| RICHMOND          | VA  | Virginia Commonwealth University           |
+-------------------+-----+--------------------------------------------+
| SAGINAW           | MI  | Saginaw Cooperative Hospitals Program      |
+-------------------+-----+--------------------------------------------+
| SALEM             | VA  | University of Virginia                     |
+-------------------+-----+--------------------------------------------+
| SALT LAKE         | UT  | University of Utah                         |
+-------------------+-----+--------------------------------------------+
| SAN ANTONIO       | TX  | University of Texas Health Sciences Center |
|                   |     | at San Antonio                             |
+-------------------+-----+--------------------------------------------+
| SAN DIEGO         | CA  | University of California - San Diego       |
+-------------------+-----+--------------------------------------------+
| SAN FRANCISCO     | CA  | University of California - San Francisco   |
+-------------------+-----+--------------------------------------------+
| SAN JUAN          | PR  | University of Puerto Rico                  |
+-------------------+-----+--------------------------------------------+
| SEATTLE           | WA  | University of Washington                   |
+-------------------+-----+--------------------------------------------+
| SEPULVEDA         | CA  | University of California - Los Angeles     |
+-------------------+-----+--------------------------------------------+
| SHREVEPORT        | LA  | Louisiana State University                 |
+-------------------+-----+--------------------------------------------+
| SIOUX FALLS       | SD  | University of South Dakota                 |
+-------------------+-----+--------------------------------------------+
| ST. LOUIS         | MO  | St. Louis University; Washington           |
|                   |     | University                                 |
+-------------------+-----+--------------------------------------------+
| SYRACUSE          | NY  | SUNY Health Science Center - Syracuse      |
+-------------------+-----+--------------------------------------------+
| TACOMA            | WA  | University of Washington                   |
+-------------------+-----+--------------------------------------------+
| TAMPA             | FL  | University of South Florida                |
+-------------------+-----+--------------------------------------------+
| TEMPLE            | TX  | Texas A&M University                       |
+-------------------+-----+--------------------------------------------+
| TOGUS             | ME  | Maine Eye & Ear Infirmary;                 |
|                   |     |                                            |
|                   |     | University of Massachusetts Medical Center |
+-------------------+-----+--------------------------------------------+
| TOPEKA            | KS  | Karl Menninger School of Psychiatry        |
+-------------------+-----+--------------------------------------------+
| TUCSON            | AZ  | University of Arizona                      |
+-------------------+-----+--------------------------------------------+
| TUSCALOOSA        | AL  | University of Alabama                      |
+-------------------+-----+--------------------------------------------+
| TUSKEGEE          | AL  | University of Alabama; Morehouse College   |
+-------------------+-----+--------------------------------------------+
| WACO              | TX  | Texas A&M University                       |
+-------------------+-----+--------------------------------------------+
| WASHINGTON        | DC  | George Washington University; Georgetown   |
|                   |     | University; Howard University              |
+-------------------+-----+--------------------------------------------+
| WEST HAVEN        | CT  | Yale University                            |
+-------------------+-----+--------------------------------------------+
| WEST LOS ANGELES  | CA  | University of California - Los Angeles     |
+-------------------+-----+--------------------------------------------+
| WHITE RIVER       | VT  | Dartmouth Medical School                   |
+-------------------+-----+--------------------------------------------+
| WICHITA           | KS  | University of Kansas Medical Center        |
+-------------------+-----+--------------------------------------------+
| WILKES-BARRE      | PA  | Hahnemann Medical College                  |
+-------------------+-----+--------------------------------------------+
| WILMINGTON        | DE  | Thomas Jefferson University                |
+-------------------+-----+--------------------------------------------+

**Appendix V. VA-Academic Affiliate (Medical School) Sharing Agreements
as of March 31, 1996**

+------------------+-----------------+------------------------+-------+
| **Facility       | **Name of       | **Medical Specialty**  | **Te  |
| Name**           | Contractor**    |                        | rms** |
+------------------+-----------------+------------------------+-------+
| VAMC Ann Arbor   | University of   | PET Scans (10)         | Exc   |
|                  | Michigan        |                        | hange |
|                  |                 |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Augusta     | Medical College | Neurology              | Exc   |
|                  | of Georgia      |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Medical College | Radiation Therapy (3)  | Buy   |
|                  | of Georgia      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Medical College | Diagnostic Radiology   | Buy   |
|                  | of Georgia      | (3)                    |       |
|                  | School of       |                        | Exc   |
|                  | Medicine        |                        | hange |
+------------------+-----------------+------------------------+-------+
|                  | Medical College | Special Surgery        | Buy   |
|                  | of Georgia      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Medical College | Allergy; Immunology    | Pr    |
|                  | of Georgia      |                        | ovide |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Baltimore   | University of   | Cardiology;            | Buy   |
|                  | Maryland        | Angioplasty; Cardiac   |       |
|                  |                 | Catheterization; ICU   |       |
|                  | School of       | (4)                    |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiothoracic Surgery | Buy   |
|                  | Maryland        | (4)                    |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy (4)  | Buy   |
|                  | Maryland        |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Bay Pines   | University of   | Pathology; Clinical    | Buy   |
|                  | South Florida   | Laboratory             |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Birmingham  | University of   | Anatomic Pathology;    | Buy   |
|                  | Alabama         | Microscopy             |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy      | Buy   |
|                  | Alabama         |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Bronx       | Mount Sinai     | Neurology              | Pr    |
|                  |                 |                        | ovide |
|                  | School of       |                        |       |
|                  | Medicine of     |                        |       |
|                  |                 |                        |       |
|                  | the City        |                        |       |
|                  | University of   |                        |       |
|                  | New York        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Mount Sinai     | Nephrology             | Buy   |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine of     |                        |       |
|                  |                 |                        |       |
|                  | the City        |                        |       |
|                  | University of   |                        |       |
|                  | New York        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC Bronx,      | Mount Sinai     | Lithotripsy            | Exc   |
| cont.            |                 |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine of     |                        |       |
|                  |                 |                        |       |
|                  | the City        |                        |       |
|                  | University of   |                        |       |
|                  | New York        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Charleston  | Medical         | Cardiology;            | Buy   |
|                  | University of   | Angioplasty; Cardiac   |       |
|                  | South Carolina  | Catheterization; ICU   |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Medical         | Magnetic Resonance     | Buy   |
|                  | University of   | Imaging                |       |
|                  | South Carolina  |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Medical         | Ophthalmology          | Buy   |
|                  | University of   |                        |       |
|                  | South Carolina  |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Medical         | Radiation Therapy      | Buy   |
|                  | University of   |                        |       |
|                  | South Carolina  |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Chicago     | Northwestern    | Liver Transplant (2)   | Buy   |
| (Lakeside)       | University      |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Chillicothe | Ohio State      | Diagnostic Radiology   | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Ohio State      | Primary Care Physician | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Cincinnati  | University of   | Radiation Therapy      | Buy   |
|                  | Cincinnati      |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Diagnostic Radiology   | Buy   |
|                  | Cincinnati      |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Buy   |
|                  | Cincinnati      | Laboratory (2)         |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Columbia    | University of   | Magnetic Resonance     | Buy   |
| (MO)             | Mi              | Imaging (4)            |       |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Exc   |
|                  | Mi              | Laboratory             | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Nephrology             | Exc   |
|                  | Mi              |                        | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Surgery        | Exc   |
|                  | Mi              |                        | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Neurology              | Exc   |
|                  | Mi              |                        | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Columbio    | University of   | Urology                | Exc   |
| (MO) cont.       | Mi              |                        | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Hematology; Oncology   | Exc   |
|                  | Mi              |                        | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiology;            | Exc   |
|                  | Mi              | Angioplasty; Cardiac   | hange |
|                  | ssouri-Columbia | Catheterization, ICU   |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Diagnostic Radiology   | Exc   |
|                  | Mi              |                        | hange |
|                  | ssouri-Columbia |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Durham      | Duke University | Radiation Therapy      | Exc   |
|                  |                 |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Duke University | Pathology; Clinical    | Exc   |
|                  |                 | Laboratory             | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Duke University | Research Animal        | Exc   |
|                  |                 |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Duke University | General Medicine (ICU) | Exc   |
|                  |                 |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Duke University | Immunocytochemistry    | Exc   |
|                  |                 |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Duke University | Cardiology;            | Exc   |
|                  |                 | Angioplasty; Cardiac   | hange |
|                  | School of       | Catheterization; ICU   |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Duke University | General Surgery        | Exc   |
|                  |                 |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Gainesville | University of   | Heart Transplant       | Buy   |
|                  | Florida         |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiology;            | Exc   |
|                  | Florida         | Angioplasty; Cardiac   | hange |
|                  |                 | Catheterization; ICU   |       |
|                  | College of      | (2)                    |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Magnetic Resonance     | Exc   |
|                  | Florida         | Imaging                | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Diagnostic Radiology   | Exc   |
|                  | Florida         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy (2)  | Exc   |
|                  | Florida         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        | Buy   |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Ophthalmology          | Exc   |
|                  | Florida         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Gynecology             | Exc   |
|                  | Florida         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Orthopedics            | Exc   |
|                  | Florida         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC Hines       | University of   | Radiation Therapy (2)  | Exc   |
|                  | Illinois        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Houston     | Baylor College  | Dermatology            | Pr    |
|                  | of Medicine     |                        | ovide |
+------------------+-----------------+------------------------+-------+
| VAMC Huntington  | Marshall        | Pathology; Clinical    | Exc   |
|                  | University      | Laboratory             | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Iowa City   | University of   | Research Animal        | Exc   |
|                  | Iowa            |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Biomedical Engineering | Buy   |
|                  | Iowa            |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Neurology              | Buy   |
|                  | Iowa            |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Medical Waste          | Buy   |
|                  | Iowa            | Incineration           |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Liver Transplant       | Exc   |
|                  | Iowa            |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Mammography            | Exc   |
|                  | Iowa            |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Exc   |
|                  | Iowa            | Laboratory             | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Anatomic;   | Exc   |
|                  | Iowa            | Microscopy             | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Medicine (ICU) | Exc   |
|                  | Iowa            |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiothoracic Surgery | Exc   |
|                  | Iowa            |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Nuclear Medicine;      | Exc   |
|                  | Iowa            | Scan;                  | hange |
|                  |                 |                        |       |
|                  | College of      | Non Image Study        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Sterile Processing     | Buy   |
|                  | Iowa            |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Jackson     | University of   | Radiation Therapy      | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiothoracic Surgery | Exc   |
|                  | Mississippi     | (2)                    | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        | Buy   |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Neurology              | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Ophthalmology (2)      | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        | Buy   |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Otolaryngology         | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy (2)  | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        | Buy   |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC Jackson,    | University of   | Magnetic Resonance     | Exc   |
| cont.            | Mississippi     | Imaging (2)            | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        | Buy   |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiology;            | Exc   |
|                  | Mississippi     | Angioplasty; Cardiac   | hange |
|                  | School of       | Catheterization; ICU   | Buy   |
|                  | Medicine        | (2)                    |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Gynecology             | Buy   |
|                  | Mississippi     |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Medicine (ICU) | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Hematology; Oncology   | Exc   |
|                  | Mississippi     |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Infectious Diseases;   | Exc   |
|                  | Mississippi     | AIDS                   | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Kansas City | University of   | Ophthalmology          | Buy   |
|                  | Kansas Medical  |                        |       |
|                  | Center School   |                        |       |
|                  | of Medicine     |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy      | Exc   |
|                  | Kansas Medical  |                        | hange |
|                  | Center School   |                        |       |
|                  | of Medicine     |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiology;            | Buy   |
|                  | Kansas Medical  | Angioplasty;           |       |
|                  | Center School   |                        |       |
|                  | of Medicine     | Cardiac                |       |
|                  |                 | Catheterization; ICU   |       |
+------------------+-----------------+------------------------+-------+
| VAMC Lexington   | University of   | General Medicine (ICU) | Exc   |
|                  | Kentucky        | (2)                    | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Specialized Space      | Pr    |
|                  | Kentucky        |                        | ovide |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Little Rock | University of   | General Medicine (ICU) | Exc   |
|                  | Arkansas        | (3)                    | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiology;            | Buy   |
|                  | Arkansas        | Angioplasty;           |       |
|                  |                 |                        |       |
|                  | College of      | Cardiac                |       |
|                  | Medicine        | Catheterization; ICU   |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Nephrology             | Exc   |
|                  | Arkansas        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Surgery        | Exc   |
|                  | Arkansas        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Special Surgery        | Exc   |
|                  | Arkansas        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Research               | Exc   |
|                  | Arkansas        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Exc   |
|                  | Arkansas        | Laboratory             | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Nuclear Medicine;      | Exc   |
|                  | Arkansas        |                        | hange |
|                  |                 | Scan; Non Image Study  |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Diagnostic Radiology   | Exc   |
|                  | Arkansas        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Little      | University of   | Ophthalmology          | Exc   |
| Rock, Cont.      | Arkansas        |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Loma Linda  | Loma Linda      | Diagnostic Radiology   | Exc   |
|                  | University      |                        | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Loma Linda      | Specialized Space      | Exc   |
|                  | University      |                        | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Louisville  | University of   | Radiation Therapy      | Buy   |
|                  | Louisville      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Madison     | University of   | Nephrology             | Buy   |
|                  | Wisconsin       |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Liver Transplant       | Buy   |
|                  | Wisconsin       |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Nuclear Medicine;      | Buy   |
|                  | Wisconsin       |                        |       |
|                  | Medical School  | Scan; Non Image Study  |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Anatomic Pathology;    | Pr    |
|                  | Wisconsin       | Microscopy             | ovide |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Neurology              | Pr    |
|                  | Wisconsin       |                        | ovide |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Diagnostic Radiology   | Pr    |
|                  | Wisconsin       |                        | ovide |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy (2)  | Buy   |
|                  | Wisconsin       |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Miami       | University of   | Magnetic Resonance     | Buy   |
|                  | Miami           | Imaging                |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Milwaukee   | Medical College | Research               | Pr    |
|                  | of Wisconsin    |                        | ovide |
+------------------+-----------------+------------------------+-------+
| VAMC Minneapolis | University of   | Diagnostic Radiology   | Buy   |
|                  | Minnesota       |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Research               | Buy   |
|                  | Minnesota       |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Pr    |
|                  | Minnesota       | Laboratory (2)         | ovide |
|                  | Medical School  |                        | Buy   |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Special Surgery        | Buy   |
|                  | Minnesota       |                        |       |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Nashville   | Vanderbilt      | Heart Transplant (3)   | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Nuclear Medicine;      | Buy   |
|                  | University      |                        |       |
|                  |                 | Scan; Non Image Study  |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Pathology; Clinical    | Buy   |
|                  | University      | Laboratory             |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | General Dentistry      | Exc   |
|                  | University      |                        | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC Nashville,  | Vanderbilt      | Neurology              | Exc   |
| cont.            | University      |                        | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | General Surgery        | Exc   |
|                  | University      |                        | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Liver Transplant       | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Radiation Therapy (2)  | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Bone Marrow Transplant | Buy   |
|                  | University      | (3)                    |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Diagnostic Radiology   | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Heart Transplant       | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Vanderbilt      | Nephrology             | Pr    |
|                  | University      |                        | ovide |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC New Orleans | University      | Magnetic Resonance     | Buy   |
|                  | Hospital        | Imaging (2)            |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Anatomic Pathology;    | Pr    |
|                  | University      | Microscopy             | ovide |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  |                 |                        |       |
|                  | New Orleans     |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC New York    | New York        | Special Surgery        | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Northport   | State           | Magnetic Resonance     | Buy   |
|                  | University at   | Imaging                |       |
|                  | Stony Brook     |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Oklahoma    | University of   | Magnetic Resonance     | Buy   |
| City             | Oklahoma        | Imaging                |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Radiation Therapy (2)  | Buy   |
|                  | Oklahoma        |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Palo Alto   | Stanford        | Radiation Therapy (3)  | Buy   |
|                  | University      |                        |       |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Stanford        | PET Scans              | Pr    |
|                  | University      |                        | ovide |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC             | University of   | Cardiothoracic Surgery | Buy   |
| Philadelphia     | Pennsylvania    |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Magnetic Resonance     | Buy   |
|                  | Pennsylvania    | Imaging                |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pulmonary Medicine     | Buy   |
|                  | Pennsylvania    | Therapist (2)          |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC Portland    | Oregon Health   | Ophthalmology          | Buy   |
|                  | Sciences        |                        |       |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Specialized Space      | Pr    |
|                  | Sciences        |                        | ovide |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Dentistry General      | Pr    |
|                  | Sciences        |                        | ovide |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | UltraSound             | Pr    |
|                  | Sciences        |                        | ovide |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Research (3)           | Buy   |
|                  | Sciences        |                        |       |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Liver Transplant (2)   | Pr    |
|                  | Sciences        |                        | ovide |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Neurology (3)          | Pr    |
|                  | Sciences        |                        | ovide |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Ophthalmology (2)      | Exc   |
|                  | Sciences        |                        | hange |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Radiation Therapy (2)  | Exc   |
|                  | Sciences        |                        | hange |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Oregon Health   | Diagnostic Radiology   | Pr    |
|                  | Sciences        | (3)                    | ovide |
|                  | University      |                        | Exc   |
|                  | School of       |                        | hange |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Reno        | University of   | Pathology; Clinical    | Exc   |
|                  | Nevada          | Laboratory             | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Richmond    | Virginia        | Dermatology            | Exc   |
|                  | Commonwealth    |                        | hange |
|                  | University      |                        |       |
|                  | Medical College |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Virginia        | Diagnostic Radiology   | Exc   |
|                  | Commonwealth    |                        | hange |
|                  | University      |                        |       |
|                  | Medical College |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC San Antonio | University of   | Radiation Therapy (5)  | Buy   |
|                  | Texas Medical   |                        |       |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Diagnostic Radiology   | Pr    |
|                  | Texas Medical   |                        | ovide |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | PET Scans (2)          | Exc   |
|                  | Texas Medical   |                        | hange |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Ultrasound             | Pr    |
|                  | Texas Medical   |                        | ovide |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Ophthalmology (2)      | Buy   |
|                  | Texas Medical   |                        |       |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Medicine (ICU) | Pr    |
|                  | Texas Medical   |                        | ovide |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pulmonary Medicine     | Buy   |
|                  | Texas Medical   | Therapist              |       |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Magnetic Resonance     | Exc   |
|                  | Texas Medical   | Imaging (2)            | hange |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Psychiatry             | Buy   |
|                  | Texas Medical   |                        |       |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Research               | Pr    |
|                  | Texas Medical   |                        | ovide |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Medical Waste          | Pr    |
|                  | Texas Medical   | Incineration (2)       | ovide |
|                  | School at San   |                        |       |
|                  | Antonio         |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC San Diego   | University of   | Anatomic Pathology;    | Pr    |
|                  | California,     | Microscopy             | ovide |
|                  |                 |                        |       |
|                  | San Diego       |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Toxicology/Drug        | Pr    |
|                  | California,     | Monitor                | ovide |
|                  |                 |                        |       |
|                  | San Diego       |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Pr    |
|                  | California,     | Laboratory (11)        | ovide |
|                  |                 |                        |       |
|                  | San Diego       |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC San Diego,  | University of   | Radiation Therapy      | Buy   |
| cont.            | California,     |                        |       |
|                  |                 |                        |       |
|                  | San Diego       |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC San         | University of   | Radiation Therapy      | Buy   |
| Francisco        | California, San |                        |       |
|                  | Francisco       |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Shreveport  | Louisiana State | Bone Marrow Transplant | Exc   |
|                  | University      | (2)                    | hange |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Radiation Therapy      | Exc   |
|                  | University      |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Radiation Therapy      | Buy   |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Ophthalmology (2)      | Exc   |
|                  | University      |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Ophthalmology          | Buy   |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Neurosurgery (2)       | Exc   |
|                  | University      |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Cardiothoracic Surgery | Exc   |
|                  | University      | (2)                    | hange |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | General Medicine (ICU) | Exc   |
|                  | University      | (2)                    | hange |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Cardiology;            | Buy   |
|                  | University      | Angioplasty;           |       |
|                  | School of       |                        |       |
|                  | Medicine in     | Cardiac                |       |
|                  | Shreveport      | Catheterization; ICU   |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Dentistry              | Buy   |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Louisiana State | Neurology              | Buy   |
|                  | University      |                        |       |
|                  | School of       |                        |       |
|                  | Medicine in     |                        |       |
|                  | Shreveport      |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC St. Louis   | Washington      | PET Scans (3)          | Exc   |
|                  | University      |                        | hange |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | St. Louis       | PET Scans (6)          | Exc   |
|                  | University      |                        | hange |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC Syracuse    | State           | Lithotripsy            | Exc   |
|                  | University of   |                        | hange |
|                  | New York Health |                        |       |
|                  | Science Center  |                        |       |
|                  | at Syracuse     |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Tampa       | University of   | Cardiology;            | Exc   |
|                  | South Florida   | Angioplasty; Cardiac   | hange |
|                  | College of      | Catheterization; ICU   |       |
|                  | Medicine        | (3)                    |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Opthomology (3)        | Exc   |
|                  | South Florida   |                        | hange |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Exc   |
|                  | South Florida   | Laboratory (3)         | hange |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Dermatology (2)        | Exc   |
|                  | South Florida   |                        | hange |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Nuclear Medicine;      | Exc   |
|                  | South Florida   | Scan;                  | hange |
|                  | College of      |                        |       |
|                  | Medicine        | Non Image Study        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Surgery (2)    | Exc   |
|                  | South Florida   |                        | hange |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAMC Tucson      | University of   | Nuclear Medicine;      | Exc   |
|                  | Arizona         |                        | hange |
|                  |                 | Scan; Non Image Study  |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Ophthalmology (2)      | Exc   |
|                  | Arizona         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Pathology; Clinical    | Exc   |
|                  | Arizona         | Laboratory (2)         | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Dermatology            | Exc   |
|                  | Arizona         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Surgery        | Exc   |
|                  | Arizona         |                        | hange |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | General Medicine (ICU) | Buy   |
|                  | Arizona         | (5)                    |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Bone Marrow Transplant | Buy   |
|                  | Arizona         | (5)                    |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Cardiology;            | Buy   |
|                  | Arizona         | Angioplasty;           |       |
|                  |                 |                        |       |
|                  | College of      | Cardiac                |       |
|                  | Medicine        | Catheterization; ICU   |       |
|                  |                 | (2)                    |       |
+------------------+-----------------+------------------------+-------+
|                  | University of   | Research               | Buy   |
|                  | Arizona         |                        |       |
|                  |                 |                        |       |
|                  | College of      |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+

+------------------+-----------------+------------------------+-------+
| VAMC West Haven  | Yale University | PET Scans (3)          | Pr    |
|                  |                 |                        | ovide |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Yale University | Research               | Buy   |
|                  |                 |                        |       |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
|                  | Yale University | Neurology              | Pr    |
|                  |                 |                        | ovide |
|                  | School of       |                        |       |
|                  | Medicine        |                        |       |
+------------------+-----------------+------------------------+-------+
| VAM&ROC White    | Dartmouth       | Pathology; Clinical    | Buy   |
| River Junction   | Medical School  | Laboratory             |       |
+------------------+-----------------+------------------------+-------+
|                  | Dartmouth       | General Medicine (ICU) | Buy   |
|                  | Medical School  |                        |       |
+------------------+-----------------+------------------------+-------+

**Appendix VI. VA-Private Sector Sharing Agreements as of**

**March 31, 1996**

+------------------+-------------------+-----------------------+-------+
| **Facility       | **Name of         | **Medical Specialty** | **Te  |
| Name**           | Contractor**      |                       | rms** |
+------------------+-------------------+-----------------------+-------+
| VAMC Albany      | North Adams       | Pathology; Anatomic;  | Pr    |
|                  | Regional Hospital | Microscopy            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Amsterdam         | Pathology; Anatomic;  | Pr    |
|                  | Memorial Hospital | Microscopy            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Seton Health      | Pathology; Anatomic;  | Pr    |
|                  | System            | Microscopy            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | MDS Hudson Valley | Pathology; Anatomic;  | Pr    |
|                  | Labs              | Microscopy            | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Alexandria  | St. Francis       | Radiation Therapy     | Exc   |
|                  | Cabrini Hospital  |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | St. Francis       | Mammography           | Buy   |
|                  | Cabrini Hospital  |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Altoona     | Altoona Hospital  | Mammography           | Buy   |
+------------------+-------------------+-----------------------+-------+
| VAMC Ann Arbor   | Foote Hospital    | Radiation Therapy     | Pr    |
|                  |                   |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Augusta     | Vascular          | Diagnostic Radiology  | Buy   |
|                  | Radiology         | (2)                   |       |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Walton            | Spinal Cord Injury    | Pr    |
|                  | Rehabilitation    |                       | ovide |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Batavia     | New York State    | Grounds Maintenance   | Pr    |
|                  |                   | (2)                   | ovide |
|                  | Veterans Home     |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | New York State    | Hospital Laundry (2)  | Pr    |
|                  |                   |                       | ovide |
|                  | Veterans Home     |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | New York State    | Pharmacy (2)          | Pr    |
|                  |                   |                       | ovide |
|                  | Veterans Home     |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | New York State    | Security (2)          | Pr    |
|                  |                   |                       | ovide |
|                  | Veterans Home     |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | New York State    | Snow Plowing (2)      | Pr    |
|                  |                   |                       | ovide |
|                  | Veterans Home     |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Bath        | St. James Mercy   | Mammography           | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Ogden Medical     | Mammography           | Buy   |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Corning Hospital  | Mammography           | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Ira Davenport     | Mammography           | Buy   |
|                  | Memorial Hospital |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Battle      | Southwest         | Magnetic Resonance    | Buy   |
| Creek            | Michigan          | Imaging               |       |
|                  |                   |                       |       |
|                  | MRI Center        |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Big Spring  | Contract Pending  | Primary Care          | Buy   |
|                  |                   | Physician             |       |
+------------------+-------------------+-----------------------+-------+
|                  | Pecos County      | Primary Care          | Buy   |
|                  |                   | Physician             |       |
|                  | Memorial Hospital |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Cogdell Memorial  | Primary Care          | Buy   |
|                  | Hospital          | Physician             |       |
+------------------+-------------------+-----------------------+-------+
|                  | Ward Memorial     | Primary Care          | Buy   |
|                  | Hospital          | Physician             |       |
+------------------+-------------------+-----------------------+-------+
|                  | La Clinics        | Primary Care          | Buy   |
|                  | Esperanza         | Physician             |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Birmingham  | Bethany Medical   | Primary Care          | Buy   |
|                  | Center            | Physician             |       |
+------------------+-------------------+-----------------------+-------+

+------------------+-------------------+-----------------------+-------+
| VAMC Boston      | University of     | Research              | Buy   |
|                  | Massachusetts     |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Buffalo     | The Resource      | Primary Care          | Buy   |
|                  | Center            | Physician             |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Castle      | Vassar Brothers   | Diagnostic Radiology  | Pr    |
| Point            | Hospital          |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Dutchess          | Diagnostic Radiology  | Exc   |
|                  | Radiology         |                       | hange |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Charleston  | Medical           | Radiation Therapy     | Buy   |
|                  | University of     |                       |       |
|                  | South Carolina    |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAM&ROC Cheyenne | Cheyenne          | Diagnostic Radiology  | Buy   |
|                  |                   |                       |       |
|                  | Radiology and     |                       |       |
|                  | MRI, Inc.         |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Columbia    | Dialysis Clinic   | Nephrology            | Buy   |
| (MO)             |                   |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Ellis Fichel      | Radiation Therapy     | Exc   |
|                  | Cancer Center     |                       | hange |
+------------------+-------------------+-----------------------+-------+
| VAMC Columbia    | Outpatient        | Diagnostic Radiology  | Buy   |
| (SC)             | Diagnostic Center |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Des Moines  | Contract Pending  | Radiation Therapy     | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Blood Center of   | Blood Bank            | Buy   |
|                  | Central Iowa      |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Northern Iowa     | General Medicine      | Buy   |
|                  | Mercy Health      | (ICU)                 |       |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Northern Iowa     | Pathology; Clinical   | Buy   |
|                  | Mercy Health      | Laboratory            |       |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Therapeutic       | Radiation Therapy     | Buy   |
|                  | Radiology         |                       |       |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Durham      | North Carolina    | Pathology; Clinical   | Pr    |
|                  | Eye Bank          | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC             | Northwest         | Radiation Therapy     | Buy   |
| Fayetteville     | Arkansas          |                       |       |
| (AK)             | Radiation Therapy |                       |       |
|                  | Institute         |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Northwest         | Radiation Therapy     | Buy   |
|                  | Arkansas          |                       |       |
|                  | Radiation         |                       |       |
|                  | Oncology          |                       |       |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Fort Meade  | Imaging Plus,     | Diagnostic Radiology  | Buy   |
|                  | Inc.              |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Imaging Plus,     | Magnetic Resonance    | Buy   |
|                  | Inc.              | Imaging               |       |
+------------------+-------------------+-----------------------+-------+
|                  | Rapid City        | Diagnostic Radiology  | Buy   |
|                  | Regional Hospital |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Rapid City        | Magnetic Resonance    | Buy   |
|                  | Regional Hospital | Imaging               |       |
+------------------+-------------------+-----------------------+-------+
|                  | Rapid City        | Radiation Therapy     | Buy   |
|                  | Regional Hospital |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Radiology         | Radiation Therapy     | Buy   |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Radiology         | Diagnostic Radiology  | Buy   |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+

+------------------+-------------------+-----------------------+-------+
| VAMC Fort Meade, | Northern Hills    | General Medicine      | Pr    |
| cont.            | Medical Center    | (ICU)                 | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Northern Hills    | General Medicine      | Pr    |
|                  |                   | (ICU)                 | ovide |
|                  | General Hospital  |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Clinical          | Pathology; Clinical   | Buy   |
|                  | Laboratory of the | Laboratory            |       |
|                  | Black Hills       |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Sturgis Community | General Medicine      | Pr    |
|                  |                   | (ICU) (3)             | ovide |
|                  | Health Care       |                       |       |
|                  |                   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Sturgis Community | Radiation Therapy     | Pr    |
|                  |                   |                       | ovide |
|                  | Health Center     |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Sturgis Community | Diagnostic Radiology  | Pr    |
|                  |                   |                       | ovide |
|                  | Health Center     |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
| VAMC Fort Wayne  | Parkview Memorial | Radiation Therapy     | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Parkview Memorial | Diagnostic Radiology  | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Gainesville | Civitan Regional  | Blood Bank            | Buy   |
|                  |                   |                       |       |
|                  | Blood Center,     |                       |       |
|                  | Inc.              |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Grand       | Nebraska State    | Pathology; Clinical   | Pr    |
| Island           | Veterans Home     | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Grand       | Western Colorado  | Diagnostic Radiology  | Buy   |
| Junction         |                   |                       |       |
|                  | Radiologic        |                       |       |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Hampton     | Riverside Medical | Radiation Therapy     | Buy   |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Hot Springs | Pine Ridge PHS    | Surgery General (3)   | Pr    |
|                  | Hospital          |                       | ovide |
|                  |                   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Pine Ridge PHS    | Diagnostic Radiology  | Pr    |
|                  | Hospital          | (3)                   | ovide |
|                  |                   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Pine Ridge PHS    | Pathology; Clinical   | Pr    |
|                  | Hospital          | Laboratory (3)        | ovide |
|                  |                   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Pine Ridge PHS    | Nuclear Medicine;     | Pr    |
|                  | Hospital          | Scan;                 | ovide |
|                  |                   |                       | Buy   |
|                  |                   | Non Image Study (3)   |       |
+------------------+-------------------+-----------------------+-------+
|                  | Pine Ridge PHS    | Podiatry (3)          | Pr    |
|                  | Hospital          |                       | ovide |
|                  |                   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Pine Ridge PHS    | General Medicine      | Pr    |
|                  | Hospital          | (ICU) (3)             | ovide |
|                  |                   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Southern Hills    | Social Work           | Exc   |
|                  | General Hospital  |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Southern Hills    | Hospital Laundry      | Exc   |
|                  |                   |                       | hange |
|                  | General Hospital  |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Southern Hills    | General Medicine      | Exc   |
|                  |                   | (ICU)                 | hange |
|                  | General Hospital  |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Houston     | Brenham Clinic    | Primary Care          | Buy   |
|                  |                   | Physician             |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Huntington  | University        | Pathology; Clinical   | Exc   |
|                  | Laboratory        | Laboratory            | hange |
+------------------+-------------------+-----------------------+-------+
| VAMC Iowa City   | Mercy Hospital    | Magnetic Resonance    | Exc   |
|                  |                   | Imaging               | hange |
+------------------+-------------------+-----------------------+-------+
|                  | University of     | Magnetic Resonance    | Buy   |
|                  | Iowa              | Imaging               |       |
+------------------+-------------------+-----------------------+-------+
|                  |                   | Radiation Therapy     | Buy   |
+------------------+-------------------+-----------------------+-------+
| VAMC Iron        | Dickinson         | Speech Pathology      | Pr    |
| Mountain         | Community         |                       | ovide |
|                  |                   |                       |       |
|                  | Mental Health     |                       |       |
|                  | Board             |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Dickinson County  | Mammography           | Exc   |
|                  | Memorial Hospital |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Dickinson County  | Nephrology            | Exc   |
|                  | Memorial Hospital |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Dickinson County  | Pathology; Clinical   | Pr    |
|                  | Memorial Hospital | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Dickinson County  | Diagnostic Radiology  | Exc   |
|                  | Memorial Hospital |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Western U.P.      | Endocrinology;        | Pr    |
|                  | District Health   | Metabolism            | ovide |
|                  | Department        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Dr. Stephen Hunt  | General Medicine      | Pr    |
|                  |                   | (ICU)                 | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC             | Vencor Hospital   | Biomedial Engineering | Pr    |
| Indianapolis     |                   |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Leavenworth | Bethany Medical   | Diagnostic Radiology  | Buy   |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Cushing Memorial  | Sterile Processing    | Pr    |
|                  | Hospital          |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Cushing Memorial  | Pathology; Clinical   | Pr    |
|                  | Hospital          | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | St. Johns         | Sterile Processing    | Pr    |
|                  | Hospital          |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Long Beach  | UCLA              | Bone Marrow           | Buy   |
|                  |                   | Transplant (2)        |       |
+------------------+-------------------+-----------------------+-------+
|                  | Rancho Los Amigos | Research              | Buy   |
|                  | Research          |                       |       |
|                  | Institute         |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Louisville  | Jewish Hospital   | Cardiology;           | Buy   |
|                  |                   | Angioplasty;          |       |
|                  |                   |                       |       |
|                  |                   | Cardiac               |       |
|                  |                   | Catheterization; ICU  |       |
+------------------+-------------------+-----------------------+-------+
|                  | Suburban Medical  | Lithotripsy           | Buy   |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Madison     | Dade County       | Hospital Laundry      | Pr    |
|                  | Infirmary         |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | American Red      | Anatomic Pathology;   | Pr    |
|                  | Cross             |                       | ovide |
|                  |                   | Microscopy            |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Martinsburg | Jefferson         | Diagnostic Radiology  | Pr    |
|                  | Memorial Hospital |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Memphis     | Baptist Memorial  | Anatomic Pathology;   | Pr    |
|                  | Hospital          |                       | ovide |
|                  |                   | Microscopy            |       |
+------------------+-------------------+-----------------------+-------+
|                  | Mid-South         | Specialized Space     | Pr    |
|                  |                   |                       | ovide |
|                  | Transplant        |                       |       |
|                  | Foundation        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Mid-South Tissue  | Specialized Space     | Pr    |
|                  | Bank              |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Mid-South Eye     | Specialized Space     | Pr    |
|                  | Bank              |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Regional Skin     | Specialized Space     | Pr    |
|                  | Bank              |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Milwaukee   | Marquette         | Pathology; Clinical   | Pr    |
|                  | University        | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+

+------------------+-------------------+-----------------------+-------+
| VAMC Minneapolis | Minnesota Lung    | Research              | Buy   |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Minnesota         | Psychiatry            | Buy   |
|                  |                   |                       |       |
|                  | State Veterans    |                       |       |
|                  | Home (MN)         |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Minnesota         | Psychiatry            | Buy   |
|                  |                   |                       |       |
|                  | State Veterans    |                       |       |
|                  | Home (Hasting)    |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Superior Memorial | Diagnostic Radiology  | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Superior Memorial | Physical Therapist    | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | St. Mary's        | Diagnostic Radiology  | Buy   |
|                  | Hospital of       |                       |       |
|                  | Superior          |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC             | Middle Tennessee  | Gynecology            | Exc   |
| Murfreesboro     |                   |                       | hange |
|                  | State University  |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Middle Tennessee  | Pathology; Clinical   | Exc   |
|                  |                   | Laboratory            | hange |
|                  | State University  |                       |       |
+------------------+-------------------+-----------------------+-------+
| Northern         | Merrithew         | General Medicine      | Exc   |
| California       | Memorial Hospital | (ICU)                 | hange |
| System of        |                   |                       |       |
| Clinics          |                   |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Nashville   | State of          | Primary Care          | Buy   |
|                  | Tennessee         | Physician             |       |
+------------------+-------------------+-----------------------+-------+
|                  | Contact Pending   | Pathology; Anatomic;  | Buy   |
|                  |                   | Microscopy            |       |
+------------------+-------------------+-----------------------+-------+
| VAMC New Orleans | Medical Center of | Radiation Therapy     | Buy   |
|                  | Louisiana         |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Louisiana Health  | Magnetic Resonance    | Buy   |
|                  | Care Authority    | Imaging               |       |
|                  | Medical Center of |                       |       |
|                  | Louisiana         |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC             | Soldiers Home     | Hospital Laundry      | Pr    |
| Northhampton     |                   |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Palm Beach  | Contract Pending  | Radiation Therapy     | Buy   |
| County           |                   |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Contract Pending  | Blood Bank            | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | JFK Medical       | Cardiology;           | Buy   |
|                  | Center            | Angioplasty;          |       |
|                  |                   |                       |       |
|                  |                   | Cardiac               |       |
|                  |                   | Catheterization; ICU  |       |
+------------------+-------------------+-----------------------+-------+
|                  | Contract Pending  | Magnetic Resonance    | Buy   |
|                  |                   | Imaging               |       |
+------------------+-------------------+-----------------------+-------+
|                  | DBA MEDCORP       | General Surgery       | Buy   |
+------------------+-------------------+-----------------------+-------+
| VAMC Pittsburgh  | Western           | Pathology; Clinical   | Buy   |
| (Highland)       | Psychiatric       | Laboratory            |       |
|                  | Institute         |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Pittsburgh  | St. Clairsville   | Primary Care          | Buy   |
| (University)     | Clinic            | Physician             |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Portland    | Independent       | Specialized Space     | Pr    |
|                  | Living Center     |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Oregon Health     | Mammography           | Buy   |
|                  | Sciences          |                       |       |
|                  | University        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | East Portland     | Mammography           | Buy   |
|                  | Imaging           |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Prescott    | Yavapai Regional  | General Medicine      | Buy   |
|                  |                   | (ICU)                 |       |
|                  | Medical Center    |                       |       |
+------------------+-------------------+-----------------------+-------+

+------------------+-------------------+-----------------------+-------+
| VAMC Providence  | Rhode Island      | Occupational Therapy  | Buy   |
|                  | Veterans Home     | (2)                   |       |
+------------------+-------------------+-----------------------+-------+
|                  | Roger Williams    | Mammography           | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Rogers Williams   | Radiation Therapy     | Exc   |
|                  | Hospital          |                       | hange |
+------------------+-------------------+-----------------------+-------+
| VAMC Richmond    | First Lithotripsy | Lithotripsy           | Buy   |
|                  | Group             |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Roseburg    | Douglas Community | Diagnostic Radiology  | Exc   |
|                  | Hospital          |                       | hange |
+------------------+-------------------+-----------------------+-------+
| VAMC Saginaw     | State Veterans    | Specialized Space     | Buy   |
|                  | Home, Marquette,  |                       |       |
|                  | MI                |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Salem       | Teleradiology     | Diagnostic Radiology  | Buy   |
|                  | Associates        | (3)                   |       |
+------------------+-------------------+-----------------------+-------+
|                  | Radiology         | Nuclear Medicine;     | Buy   |
|                  | Association of    |                       |       |
|                  | Roanoke           | Scan; Non Image Study |       |
+------------------+-------------------+-----------------------+-------+
|                  | Roanoke ENT       | Otolaryngology        | Buy   |
|                  | Clinic            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Roanoke Memorial  | Mammography (2)       | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Adult Care Center | Extended Care         | Exc   |
|                  | of Roanoke        |                       | hange |
|                  | Valley, Inc.      |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Roanoke Memorial  | Radiation Therapy     | Exc   |
|                  | Hospital          |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Lewis Gale        | Magnetic Resonance    | Buy   |
|                  | Hospital          | Imaging               |       |
+------------------+-------------------+-----------------------+-------+
| VAMC San Antonio | Southwest Texas   | General Medicine      | Pr    |
|                  |                   | (ICU)                 | ovide |
|                  | Methodist         |                       |       |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Cancer Therapy    | Radiation Therapy     | Exc   |
|                  | and               |                       | hange |
|                  |                   |                       |       |
|                  | Research Center   |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Cardiometrix,     | Diagnostic Radiology  | Buy   |
|                  | Inc.              |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Bexar County      | Research              | Buy   |
|                  | Hospital District |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Bexar County      | Pathology; Clinical   | Buy   |
|                  | Hospital          | Laboratory            |       |
+------------------+-------------------+-----------------------+-------+
|                  | The Cancer        | Radiation Therapy (2) | Exc   |
|                  | Therapy and       |                       | hange |
|                  | Research Center   |                       | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Bexar County      | General Medicine      | Exc   |
|                  | Hospital District | (ICU)                 | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Bexar County      | Cardiology;           | Exc   |
|                  | Hospital          | Angioplasty; Cardiac  | hange |
|                  |                   | Catheterization;      |       |
|                  |                   | (ICU)                 |       |
+------------------+-------------------+-----------------------+-------+
|                  | Bexar County      | Bone Marrow           | Exc   |
|                  | Hospital District | Transplant            | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Victoria Regional | Radiation Therapy     | Buy   |
|                  | Medical Center    |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Corpus Christi    | Diagnostic Radiology  | Buy   |
|                  | Radiology Center  |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Beyar County      | Magnetic Resonance    | Exc   |
|                  | County Hospital   | Imaging               | hange |
|                  | District          |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC San Diego   | Sharp Rees-Sealy  | Pathology; Anatomic;  | Pr    |
|                  |                   | Microscopy            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Redwood Elderlink | Extended Care         | Buy   |
+------------------+-------------------+-----------------------+-------+
| VAMC Shreveport  | Contract Pending  | Primary Care          | Buy   |
|                  |                   | Physician             |       |
+------------------+-------------------+-----------------------+-------+
|                  | Medical           | Magnetic Resonance    | Buy   |
|                  | Synergies, Inc.   | Imaging               |       |
+------------------+-------------------+-----------------------+-------+
| VAM&ROC Sioux    | Neurology         | Neurology             | Buy   |
| Falls            | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | McKennan Hospital | Diagnostic Radiology  | Buy   |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Falls       | Sterile Processing    | Pr    |
|                  | Surgical Center   |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Children's Care   | Audiology             | Pr    |
|                  | Hospital          |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Vocational  | General Medicine      | Pr    |
|                  | Services          | (ICU)                 | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Valley      | Cardiology;           | Buy   |
|                  | Hospital          | Angioplasty;          |       |
|                  |                   |                       |       |
|                  |                   | Cardiac               |       |
|                  |                   | Catheterization; ICU  |       |
|                  |                   | (2)                   |       |
+------------------+-------------------+-----------------------+-------+
|                  | Minnesota         | Primary Care          | Pr    |
|                  | Veterans Home     | Physician             | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Valley      | Pharmacy              | Buy   |
|                  | Hospital          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Dow-Rummel        | Dietetics             | Pr    |
|                  | Village           |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | North Central     | Urology               | Buy   |
|                  | Urology PC        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Valley      | Laundry               | Pr    |
|                  | Hospital          |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Valley      | Pathology; Clinical   | Pr    |
|                  | Hospital          | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | USD School of     | Pathology; Clinical   | Pr    |
|                  | Medicine          | Laboratory            | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Plastic Surgery   | Plastic Surgery       | Buy   |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Orthopedic        | Orthopedics           | Buy   |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | University        | Gynecology            | Buy   |
|                  | Physicians        |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | BP Health         | Medical Waste         | Pr    |
|                  | Services          | Incineration          | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Sioux Vocational  | General Medicine      | Pr    |
|                  | Services          | (ICU)                 | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Minnesota State   | Laundry               | Pr    |
|                  | Veterans Home     |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Minnesota State   | General Dentistry     | Pr    |
|                  | Veterans Home     |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Dermatology       | Dermatology           | Buy   |
|                  | Associates        |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Tampa       | H. F. Moffit      | Cardiology;           | Pr    |
|                  | Cancer Center     | Angioplasty;          | ovide |
|                  |                   |                       |       |
|                  |                   | Cardiac               |       |
|                  |                   | Catheterization; ICU  |       |
+------------------+-------------------+-----------------------+-------+
|                  | H. F. Moffit      | Nephrology            | Pr    |
|                  | Cancer Center     |                       | ovide |
+------------------+-------------------+-----------------------+-------+
|                  | Moffit Cancer     | Radiation Therapy     | Pr    |
|                  | Center            |                       | ovide |
+------------------+-------------------+-----------------------+-------+
| VAMC Tomah       | Terrence R.       | Specialized Space     | Buy   |
|                  | Barkalow, M.D.    |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAMC Waco        | Hamilton Rural    | Primary Care          | Buy   |
|                  | Family Clinic     | Physician             |       |
+------------------+-------------------+-----------------------+-------+
| VAM&ROC White    | Alice Peck Day    | Pathology; Clinical   | Pr    |
| River Junction   |                   | Laboratory            | ovide |
|                  | Memorial Hospital |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Monadnock Family  | Psychology            | Exc   |
|                  | Services          |                       | hange |
+------------------+-------------------+-----------------------+-------+
|                  | Monadnock Family  | Psychiatry            | Exc   |
|                  | Services          |                       | hange |
+------------------+-------------------+-----------------------+-------+

+------------------+-------------------+-----------------------+-------+
| VAM&ROC White    | Northeast Kingdom | Psychiatry            | Exc   |
| River Junction,  |                   |                       | hange |
| cont.            | Mental Health     |                       |       |
|                  | Services          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Northeast Kingdom | Psychology            | Exc   |
|                  |                   |                       | hange |
|                  | Mental Health     |                       |       |
|                  | Services          |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Washington County | Psychiatry            | Exc   |
|                  |                   |                       | hange |
|                  | Mental Health     |                       |       |
|                  | Service, Inc.     |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Washington County | Psychology            | Exc   |
|                  |                   |                       | hange |
|                  | Mental Health     |                       |       |
|                  | Service, Inc.     |                       |       |
+------------------+-------------------+-----------------------+-------+
| VAM&ROC Wichita  | St. Joseph        | Radiation Therapy     | Exc   |
|                  | Medical Center    |                       | hange |
+------------------+-------------------+-----------------------+-------+
| VAMC             | Geisinger Wyoming | Magnetic Resonance    | Exc   |
| Wilkes-Barre     | Valley Medical    | Imaging               | hange |
|                  | Center            |                       |       |
+------------------+-------------------+-----------------------+-------+
|                  | Robert Packer     | Pathology; Clinical   | Buy   |
|                  | Hospital          | Laboratory            |       |
+------------------+-------------------+-----------------------+-------+

Appendix VII. Criteria for Potential Realignment of VHA Facilities and
Programs

September 1995

Criteria for Potential Realignment of VHA Facilities and Programs

In anticipation of reduced funding for the next several years, the
following criteria have been compiled to assist VHA\'s field management
identify opportunities for achieving administrative or other
efficiencies that would allow VA to preserve as much patient service
capacity as possible, either directly through VA facilities or
indirectly through contractual arrangements. These criteria should be
used as screening guidelines to evaluate both facility and program
realignment possibilities.

As with any screening criteria, potential realignment opportunities
identified by these criteria would need to be further analyzed,
especially when comparing VA to community facilities where the data may
not be directly comparable for a number of reasons. Likewise, before
deciding that \"realignment\" of a facility or program is the best
option, candidate realignment opportunities would need to be carefully
evaluated for potential improved efficiency or improved quality and
compared with alternative options. Once implemented, the realignment
decision would need to be carefully evaluated for its effect on quality
of care, cost effectiveness, accessibility to care and other relevant
factors.

In considering savings generated from any program or facility
realignment, the goal should be the reduction of both fixed and variable
costs. This would typically result from the elimination of a program or
a production unit (e.g., ward) and the resulting reduction of staff,
maintenance and other program support. If program/production unit
elimination cannot be accomplished, then only the lesser variable costs
will be saved (This is typically only 10-20% of what can be saved if
both fixed and variable costs are reduced.).

In considering these criteria and potential efficiency opportunities,
managers are reminded of VA\'s unique policy objectives and goals
related to our special emphasis programs such as spinal cord injury,
blind rehabilitation, prosthetics, homelessness, etc. Similarly, VA\'s
education and research missions also have to be factored into the
consideration.

In addition to using these criteria for potential facility and/or
program realignment, they are also relevant for the siting of new
facilities and for instituting new programs and procuring new technology
at existing facilities.

**REALIGNMENT CRITERIA AND HYPOTHETICAL EXAMPLES**

**1. Availability of the same kind of service(s) of equal or higher
quality in the community at a lower cost.**

**Hypothetical Example 1:** Hemodialysis at Alpha VAMC, a major urban
teaching hospital, is provided for 196 patients a year at an average
cost of \$350 per treatment. Hemodialysis Practice, Inc. (HPI), an
outpatient community healthcare provider, charges an average of \$220
per dialysis treatment. HP can provide dialysis at a lower cost because
it does not have all the overhead associated with being part of a large
hospital. Unless Alpha VAMC can reduce its hemodialysis treatment costs,
while maintaining its quality, then it should consider discontinuing its
hemodialysis program and contracting with HPI for hemodialysis services.
The savings could be used to augment Alpha\'s primary care clinic so as
to reduce the waiting time for appointments.

**Hypothetical Example 2:** South Sigma VAMC is a 440 bed highly
affiliated tertiary care hospital having a 119 bed nursing home care
unit (NHCU). The occupancy rate of South Sigma\'s NHCU averages 95
percent, and it has an admission waiting time of 10 weeks. Fourteen of
the NHCU beds are a locked psychiatric ward, and 4 beds are set up for
ventilator dependent patients. A recent study has shown that the average
daily cost of caring for patients on South Sigma\'s NHCU is \$197. There
are 6 free standing skilled nursing facilities within a 2 mile radius of
South Sigma VAMC. A market survey of these six facilities revealed their
average occupancy rate and average daily cost to be 87 percent and \$96,
respectively. If South Sigma VAMC contracted its low acuity nursing home
patients to these facilities, then 39 beds (2 wards) of the NHCU could
be deactivated. South Sigma VAMC should consider contracting out its low
acuity nursing home patients, redirecting the savings achieved from
deactivating the 2 wards to hire a pulmonologist to augment their
understaffed respiratory disease clinic and to open a community based
clinic in an underserved part of town.

**2. Availability of the same kind of service(s) of equal or higher
quality at another VA facility within approximately sixty minutes
average ground transport travel time.**

**Hypothetical Example 1:** Epsilon VAMC, a rural secondary care
facility, has one urologist on staff, and he performs transurethral
resections of the prostate (TURPs) on patients as needed. For the last
three years an average of 19 TURPs a year have been performed at
Epsilon. Beta VAMC, a tertiary care facility located 80 miles from
Epsilon, has 3 urologists and performs an average of 193 TURPs per year.
TURP patients at Epsilon have a readmission rate for postoperative
bleeding that is twice as high as at Beta VAMC, and they are 1.5 times
as likely to get a post-operative infection. Epsilon should consider
referring its patients needing TURP to Beta VAMC.

**3. Number of procedures performed or services delivered is below
generally accepted community standards guidelines for productivity or
proficiency.**

**Hypothetical Example 1:** The American College of Good Heart Surgery
(ACGHS) certification standard for an open heart surgery program is that
it must perform at least 250 surgeries in a 12 month period. Delta VAMC,
a tertiary care university-affiliated hospital performs only 1 00 heart
surgeries a year, while its academic affiliate performs 300. Delta VAMC
should consider contracting with the university hospital for its heart
surgery cases if its caseload cannot be adequately increased by
referrals from other VAMCS.

**4. Quality of care is less than that available in the community or at
other nearby VA facilities, as measured by mortality or morbidity rates
or other appropriate performance or outcome indicators.**

**Hypothetical Example 1:** A review of surgeries at the North Gamma
VAMC, a non-affiliated 110 bed secondary care hospital, indicated a
12-month mortality rate 57 percent higher than at Alpha and Beta VAMCS,
the other two VA hospitals in the state. North Gamma\'s surgical
mortality rate was 51 percent higher than the VA systemwide average for
surgeries on similar risk patients, and 39 percent higher than private
hospitals in the state. Unless the outcomes for North Gamma\'s surgical
program can be quickly improved, then it should consider closing its
surgical program, with its cases being referred to Alpha and Beta VAMCs
or contracted to the community.

**5. Projected demand for service(s) are is significantly decreasing.**

**Hypothetical Example 1:** A review of the out-migration of veterans
from this northern state from 1985 through 1993 indicates that it
experienced a net loss of 17 percent of its veteran population over age
65. Preliminary evidence suggests that the trend is continuing. Theta
VAMC had planned to build a new nursing home care unit for \$14 million.
Community nursing home occupancy rates in the area average 82 percent.
Given the demographic change and community nursing home capacity, then
the decision to build a new VA nursing home should be reconsidered.

**6. Disproportionate or unjustifiably high resource consumption, as
evidenced by the annual average expenditure per patient being more than
150 percent of the national mean expenditure per patient for similar
facilities or clinical cohorts and/or the average length of stay (LOS)
being more than 150** **percent of the national average LOS.**

**Hypothetical Example 1:** Patients having inguinal hernia repairs at
Delta VAMC have an average LOS of 4.6 days. The community hospital
across the street from Delta has an average LOS of 2.2 days for this
procedure. The VA national average LOS for inguinal hernia repair is 2.7
days. Alpha and Beta VAMCs, both located within 120 miles of Delta VAMC,
have an average LOS for inguinal hernia repairs of 2.0 and 2.9 days,
respectively. If Delta cannot substantially reduce its average LOS for
hernia repairs, and keep quality high, then it should consider
discontinuing inguinal hernia repairs, and perhaps its entire surgery
program, sending the patients to either Alpha or Beta VAMC or
contracting with the community hospital for such service.

**Hypothetical Example 2:** West Chi VAMC is a 230 bed psychiatric
hospital having 26 of its beds dedicated to in-patient substance abuse
treatment. The average LOS for these beds is 44 days. A recent analysis
of this treatment program revealed an average treatment cost of \$7,600
per patient and a one year post-treatment sobriety rate of 62 percent.
The same study demonstrated that the 7 other VAMCs in the VISN had
shifted their substance abuse treatment programs to an outpatient
setting, as had the 4 private hospitals in the region who offered such
treatment, The average cost per patient and one year sobriety rate for
the 7 other VAMCs were \$1,860 and 63 percent, respectively. West Chi
VAMC should consider changing to an outpatient substance abuse treatment
program or contracting with one of the other VAMCs for this service. The
savings accrued by so doing could be used to fund a new vet center and a
community based clinic in a nearby town.

**7. Integration, consolidation or merger of duplicate or similarly
intended services at nearby VA facilities would yield significant
administrative and/or staffing efficiencies.**

**Hypothetical Example 1:** Cyborgville, a slowly growing metropolis
with a convenient and affordable mass transit system, hosts two large
VAMCs having similar missions. Each facility is independently managed
with separate executive, administrative and clinical infrastructures and
programs. VA primary service areas arbitrarily divide Cyborgville into
two defined catchment areas. In reality, however, the service areas
overlap across programs, facilities and population cohorts. A study
shows that \$1 .7 million of overhead costs could be saved each year if
the management and clinical services at the two VAMCs were merged.
Consolidation of the two facilities should be considered, with the saved
overhead funds being used to augment their primary care clinics and to
site a new community based clinic in a nearby rural community.

**8. Need for a clinical program presence can be reduced or eliminated
by new technology or expanded automation. In considering new technology
or automation, both capital and operating costs for the new equipment
should be included in the cost-effectiveness analysis.**

**Hypothetical Example 1:** Kappa VAMC, a moderate-sized rural VAMC, has
a two-physician radiology department, while Mu VAMC, a tertiary care
teaching hospital affiliated with Smart University 150 miles away, has a
ten-physician radiology department. Mu VAMC has just installed a PACS
system, and for an additional \$130,000 it could connect Kappa to the
PACS so that Mu\'s radiologists could read all of Kappa\'s radiographs.
Mu could provide this radiologist service for an on-going annual cost of
\$85,000. Consideration should be given to eliminating the two
radiologist positions at Kappa and adding Kappa VAMC onto Mu\'s PACS
system.

**9. A program is of very high cost, benefits few veterans (particularly
service-connected veterans), and is not an intrinsically veteran-related
service.**

**Hypothetical Example 1:** Beta VAMC in East Pink, a stable
metropolitan area of 700,000 people, provides neurosurgical services. An
average of 12 craniotomies per year have been performed for the past
three years. Sixty percent of these have been for repair of aneurysms,
and 30 percent for brain tumors. The average age of Beta\'s
neurosurgical patients is 66. The overall dedicated cost of maintaining
the neurosurgical program is \$923,000 per year. University of Red,
located about 7 miles north of Beta VAMC, is willing to contract for
neurosurgical care at an average cost of \$20,000 per craniotomy. Beta
VAMC should consider closing its neurosurgical service and contracting
with the University of Red Hospital. The savings could be redirected to
site two new community based clinics in southern East Pink.

**10. The same kind of service(s) of equal or higher quality and of
equal cost as that provided at a VAMC may be purchased in the community
and the community provider is more convenient for patients.**

**Hypothetical Example 1:** Delta Pi VAOPC is an independent outpatient
clinic located in the city of Magellan. It is the clinic of jurisdiction
for 33 counties, providing services to 17,000 veterans who live in these
counties. When non-emergency/non-urgent inpatient care services are
required, veterans are referred via shuttle or ambulance to either Alpha
or Beta VAMCS, located 179 and 112 miles away, respectively. Many of
these veterans are unhappy about having to be hospitalized so far away
from their homes. University of Get Ahead has a 320-bed hospital in
Magellan that has an average occupancy rate of 72 percent. It would like
to lease a 20-bed ward to the VA. In the interest of patient
satisfaction, Delta Pi VAOPC should consider leasing these beds from the
university, assuming it can negotiate a price that is at least
comparable to the cost of providing the service at Alpha or Beta VAMCs
and that the quality of care is as good or better.

Appendix VIII. Dialysis Technical Advisory Group's Recommendations for
Cost Savings Interventions

GUIDELINES/RECOMMENDATIONS FOR

PROVISION OF NETWORK DIALYSIS SERVICES

Developed by a Subgroup of the Dialysis Technical Advisory Group

February 1996

[I. Guidelines/recommendations for potential COST reduction in dialysis
programs]{.underline}

a\. Eliminate smaller, less productive dialysis units.

Units with less than 20 patients frequently have difficulty achieving
efficiencies of staffing, supplies, and equipment, although it may be
important to maintain such units if they provide cost-effective
mechanisms for serving acute dialysis needs (e.g., support for cardiac
surgery).

b\. Consolidate programs to reduce redundancy of services and reduce the
cost of services.

Dialysis programs that are geographically close together (e.g., 20 miles
apart) should be reviewed for possible consolidation which could
increase efficiencies in terms of purchasing power and efficient
utilization of staff and space.

c\. Consider eliminating or markedly curtailing contract dialysis
services which charge above the Medicare rate and/or are more expensive
than VA care.

When contracting is desired or needed, contracting rates should be
negotiated at a rate no higher than the Medicare rate (approximately
\$130 per outpatient treatment plus \$200 per patient per month for
physician capitation). The work group believes that immediate cost
savings can be made by paying no higher than the Medicare rate for
contracted services and auditing to assure that billing is correct.
Quarterly reviews for quality and cost effectiveness for all patients on
contract is recommended as well as developing cost/quality/access
reviews with specific criteria for all new patients needing contract
dialysis prior to approval of new contracts.

d\. Adjust staffing ratios to eliminate unnecessary or excessive
staffing.

Typically the staffing ratio for most private dialysis programs is
2.5-3.5 patients per FTE of treatment staff which includes only
physicians, nurses, technicians, dietitians, and social workers. (To
obtain the staffing ratio, divide the total number of dialysis patients
by the total number of FTE of this treatment staff.) The important point
is that there needs to be consistency in how staff are counted.

e\. Incorporate and facilitate cost saving measures such as dialyzer
re-use; more efficient utilization of expensive treatment strategies
such as erythropoietin (e.g., subcutaneous administration rather than
intravenous); case management of patients; alignment of dialysis
technicians under the management of nurses; and provision of cost data
to the dialysis until managers for ongoing reviews and dialysis.

f\. Transfer of Medicare eligible patients to non-VA programs.

[II. Guidelines for assessment of COST]{.underline}

VAMC Loma Linda has conducted a [cost]{.underline} comparison study of
dialysis services available through VA and through local private
facilities (attachment not included here). This methodology can be
utilized as a template to compare costs of existing VA Services with
those of non-VA providers. Important data elements include costs for:

-   FTE

-   Disposable (includes dialyzers and supplies)

-   Equipment

-   Contracts. Contract costs for dialysis, machine maintenance, and/or

-   water treatment.

-   Beneficiary travel

-   Pharmacy costs

-   Other related costs.

Note that in the Loma Linda study, costs for dialysis are segregated
from other treatment costs as an essential step in comparing VA costs
with those that may be available via contract. Loma Linda also found
that utilizing more specific data sources, e.g., actual salary costs for
those personnel assigned to the dialysis unit.

Caution should be taken when comparing VA to non-VA costs for dialysis.
For example, erythropoientin and other outpatient pharmacy, vascular
surgery, ICU dialysis, and some labor and/or other service costs are
[not]{.underline} typically included in the costs per outpatient
dialysis treatment by private sector facilities. Similarly, the non-VA
physician capitation charges must be considered as well as the non-VA
charges for ICU dialysis. It is, consequently, important to clearly
identify the methodology utilized by non-VA facilities when conducting
cost comparisons.

[Measurements of Work:]{.underline} As costs are assessed, parallel
measures of workload should also be obtained. Such workload measures as
those identified below could be utilized:

\# Patients enrolled in dialysis program

\# ICU treatments

\# Inpatient dialysis treatments

\# Outpatient dialysis treatments

\# Home dialysis treatments (NB: Hemodialysis patient = 3 treatments

per week; Peritoneal Dialysis (PD) patient = 3 treatments per week,.

regardless of number of exchanges performed)

Cost/patient/exchange

\# of patients on contract dialysis

[III. Guidelines/recommendations for assessment of QUALITY]{.underline}

Quality measures are necessary to assure the effectiveness of the
services provided and the accomplishment of specific patient outcomes.
The following quality measures could be employed:

-   Hematocrit levels (Hematocrit \>30% in at least 50% of patients
    treated)

-   Albumin Levels (Albumin levels of \> 3.5 in at least 75% of patients
    treated)

-   Indices of Adequacy of Dialysis (Kt/V or URR) (50% of patients
    treated should have a Kt/V\>/=1.2 or urea reduction ratio\>65%).

-   Mortality data (i.e., no more than 30% of chronic dialysis patients
    treated per year).

VA facilities not meeting cost or quality targets should be reviewed for
potential program changes or closure. Similarly, private facilities not
meeting these guidelines should not be considered for potential
contracts for dialysis care.

[IV. Guidelines/recommendations for assessment of ACCESS TO
CARE]{.underline}

Networks are responsible for provision of dialysis services within their
VISN catchment area. Critical decisions to provide dialysis care must
include considerations of access. Each network will need to develop
local decision rules governing the employment of in-house contracts or
fee-basis services for veterans needing dialysis within the VISN
catchment area. The following criteria may be employed to address
program access:

-   Capacity of Existing VA Programs

-   Travel Distance (e.g., 50 miles)

-   Travel Time (e.g., one hour)

-   Existing Capacity in Community

-   Continuity of Care/Fragmentation of Care (e.g., a patient

    receive contract dialysis services but receive the

    may remainder of his/her care in VA; the risk of medication

    errors, need for hospitalization for complications and other

    disorders, must be considered when such strategies are employed).

-   Access to acute dialysis. At the very minimum, all inpatients

    should have access to acute dialysis and tertiary care VAMCs

    must be able to provide in-house acute dialysis.

-   Access to chronic dialysis. At a minimum, current eligibility

    requires offering dialysis treatment under VA auspices to all

    patients service connected (SC) for renal disease or SC for

    any condition at 50% or more. In addition, Persian Gulf War

> veterans, as well as those exposed to Agent Orange and those
>
> eligible for the VA's Ionizing Radiation program,
>
> should be provided dialysis if the physician has deemed the problem as
>
> possible related to these exposures.

[V. Other Considerations]{.underline}

A. Research and Education

The Work Group recognized the importance of VA's commitment to research
and education, as well. It is recommended that these activities be
recognized and integrated into the decision-making process.

B. DoD

We have an obligation to support DoD and EMPO in terms of providing
back-up in times of national crises. In addition, recent VA/DoD
initiatives to explore ways to enhance the quality of patient care and
increase efficiency through greater integration are underway.
Consideration should be given to innovative sharing agreements with DoD
and the private sector.

Appendix IX. The Blended Rates Methodology and Distribution

The Blended Rates Methodology and Distribution

The Veterans Health Administration has implemented a new pricing policy
called "blended rates" for allocating the Fiscal Year 1996 budget.
Blended rates was adopted to implement the following Agency policies for
Fiscal Year 1996:

-   Create funding pools for the newly appointed Network Directors to
    provide them with resources to redirect within the VISN;

-   Increase contingency reserves above previous year's levels to
    protect against financial stress created by reductions in the 1996
    budget;

-   Begin to level the playing field by moving more resources than in
    previous years from relatively high-expenditure to low-expenditure
    networks; and,

-   Begin moving allocation away from facility specific prices to
    national prices as a first step toward capitated rates.

In 1996, the blended rates were used to remove funds from facilities'
budgets based on their relative efficiency. Relatively high cost
facilities lost more funds than relatively efficient facilities. The
funds made available through the blend were distributed to the Network
Directors to establish their spending pools for the year. The
distribution was based on: (1) restoring funds *for one year only* to
the VISN's that would have been reduced under the blend below the 1995
level, and (2) a per capita national average price which gave relatively
more to lower cost Networks and relatively less to higher cost Networks.
Through this process, the four policies established for the 1996
allocations were implemented.

**Definition of blended rates**

Blended rates is a method to set prices for prospective VA medical care
workloads. Under blended rates, a unit price for expected workload is
established by adding together a percentage of the individual facility's
unit price, the peer group average price (MCG), the geographic area
average price (VISN) and the VA national average price. The unadjusted
proportions add up to 100 percent. For example, as applied in the fiscal
year 1996 budget allocations, the blended rate has been constructed from
a blend of 70 percent of the facility's price, 5 percent of the Medical
Center Group (MCG) unit price, 5 percent of the VISN unit price, and 20
percent of the national unit price. The impact on a facility is
relatively easy to determine. Under the blend, if a facility's unit
price is lower than the price of its Medical Center Group, its VISN, or
the nation, the facility will have its prospective unit price increased
above its historical price. Conversely, a facility's prospective unit
price will be lowered if its historical prices are higher than the
prices of its MCG, its VISN or the nation.

**How blended rates work**

A VA Medical Center's unit price is computed by dividing its
expenditures by the workload it accomplished. Unit prices from a Medical
Center's peer group, VISN, and the national unit price is then blended
with the VAMC unit price. Before a blended rate is computed, however,
each VAMC's expenditure base and workload is adjusted for research,
training, special programs and special salary rates. These funding
adjustments recognize the inherent differences in VA medical centers and
make the comparisons more valid and supportable. The objective of
blending medical center group prices, geographic prices, and national
prices with each facility's price performance in each of the five RPM
(Resource Planning and Management) patient care groups is to promote
efficiency and more equitable access to care by veterans across the
Nation. The medical center group component supports efficiency within
the peer group as VAMCs with prices in excess of their MCG prices have
their prices reduced to become more in line with their peers. A VISN
price promotes geographic inter-facility coordination and efficiency.
The use of a national price factor in the blended rates reflects the
single system focus and is an approximation of capitation pricing.

**Estimated 1996 Allocation**

The attached table provides the distribution of funding for fiscal year
1996 compared to 1995 with changes in dollars and percent at the various
organizational levels. Please note that the 1996 distribution is only an
estimate\--items such as equipment funds are not allocated until later
in the fiscal year. The unallocated funds have been prorated based on
the allocation of these funds in 1995. This is intended to present an
approximation at this time for comparative purposes.

**FY 1995 ALLOCATIONS AND ESTIMATES FOR FY 1996**

**(dollars in thousands)**

  ------------- ----------------- --------------- -------------- --------------
                                                                 

                **FY 1995**       **FY 1996**     **CHANGE**     

  **VISN**      **ALLOCATIONS**   **ESTIMATES**   **DOLLARS**    **PERCENT**

                                                                 

  1             \$ 944,829        \$ 956,422      \$ 11,416      1.208%

  2             468,353           473,670         5,317          1.135%

  3             1,091,513         1,103,139       11,626         1.065%

  4             816,958           849,811         32,853         4.021%

  5             480,735           496,039         15,304         3.183%

  6             735,724           750,333         14,609         1.986%

  7             830,710           868,140         37,430         4.506%

  8             985,310           1,034,695       49,385         5.012%

  9             728,691           760,992         32,301         4.433%

  10            550,584           562,979         12,395         2.251%

  11            735,553           735,427         (-126)         (-0.017%)

  12            912,436           934,968         22,532         2.469%

  13            448,208           471,860         23,652         5.277%

  14            324,932           339,965         15,033         4.627%

  15            627,377           645,344         17,967         2.864%

  16            958,135           1,004,361       46,226         4.825%

  17            824,461           839,793         15,332         1.860%

  18            545,144           554,548         9,404          1.725%

  19            416,970           429,031         12,061         2.893%

  20            617,868           646,771         28,903         4.678%

  21            781,149           795,126         13,977         1.789%

  22            993,716           995,993         2,277          0.229%

  Centralized   384,804           380,770         (-4,034)       (-1.048%)
  Support                                                        

                                                                 

  TOTAL         \$ 16,204,160     \$ 16,630,000   \$ 425,840     2.628%
  ------------- ----------------- --------------- -------------- --------------

Appendix X

VA Enhanced Use Lease Arrangements Under Development

**Atlanta, GA VHA** *Regional Office Collocation/Mixed-Use Office
Complex* **\--** A VBA regional office and commercial private
development is currently under review for a VA-owned six-acre parcel
adjacent to the existing VAMC campus. The private development would
assist in financing the collocation as well as a potential revenue
generator for VA medical care accounts.

**Dallas, TX** Enhanced-Use commercial *Cyclotron/Medical Isotope*
center \-- Industry forum held.

**Durham, NC** *Mixed-Use Development Project* **\--** VAMC land to be
leased to a developer for mixed use, hotel/office/retail and parking
facilities in return for consolidation and relocation of VA research
space from existing hospital, and obtaining additional primary care and
administrative space, and private management of the VAMC parking
operation.

**Houston, TX** *VBA Regional Office Collocation/Mixed-Use Retail
Center* **\--** A VBA regional office and commercial private
development. First phase of private development (neighborhood medical
services/retail center) has opened on the grounds of the VAMC. The
private development has already generated an up-front payment to VA and
is currently paying an annual minimum rent plus 10 percent of the gross
proceeds to VA funding accounts. The commercial development is now
undergoing expansion that will generate additional revenues for VA. The
project was awarded Vice President Gore's Hammer award.

**Indianapolis, IN** *Consolidation Project* **\--** An Enhanced-Use
lease with the State of Indiana is being pursued as a means for
financing the consolidation of the Cold Springs Road Division of VAMC
Indianapolis onto the medical center's West Tenth Street Division. Lease
execution is scheduled for June 1996.

**Minneapolis, MN** *Enhanced-Use Managed Care Partnership* **\--** The
VAMC is negotiating with a healthcare provider to develop and operate an
outpatient clinic on VAMC campus in return for a Managed Care Clinical
Research & Education Center to be constructed in such facility for
exclusive VA use.

**Mountain Home, TN** *VA/ETSU Joint Project* **\--** The VAMC is
negotiating with Eastern Tennessee State University Medical School and
State of Tennessee for a 35-year lease of approximately 30.5 acres
consisting of eight VAMC buildings to be occupied by the ETSU Medical
School. Proposed federal funding (through the major construction
appropriation) and the state of Tennessee funding will finance the
construction of the new \$36 million medical school facility at the
northern end of the leased property. As fair consideration, VA hopes to
obtain long term maintenance services from the state.

**Providence, RI** *Renovation of Bldg. 31* **-**- The VAMC will conduct
a market and feasibility study to investigate potential development
markets for the Our Lady of Providence School. The study will look at
research use and assisted living as potential private uses that could
optimize the use and return on VA's asset, and translate into
administrative space for the VAMC. Relocation and consolidation of
administrative space would free up hospital space for direct patient
care.

**Residential Care and Temporary Lodging Facilities:** Pending
initiatives include: assisted and independent living, skilled nursing,
hotel, veteran temporary lodging and hospice facilities. In return for
the lease "rent" to VA can include: guaranteed access to such services
at no cost or reduced rates, construction of new or renovation of
existing VA facilities, or monetary consideration. The following medical
centers are pursuing residential care and temporary lodging facilities:

  ------------------------------------ ----------------------------------
  **Palo Alto, CA** *skilled nursing   **Minneapolis, MN** *veteran
  home* on existing VA golf course,    temporary lodging* & *senior
  business plan under review           housing*, business plan under
                                       review

  **Minneapolis, MN** *veteran's       **Murfreesboro, TN** *assisted
  hospice,* business plan under        living/continuing care
  development                          retirement,* business plan under
                                       development

  **VAMC Dublin, GA** *assisted        **North Chicago, IL** *assisted
  living,* business plan under review  living,* business plan under
                                       development

  **Durham, NC** *hotel*, business     **Mountain Home, TN** *assisted
  plan under development               living,* business plan under
                                       development
  ------------------------------------ ----------------------------------

**Energy Plants and Related Support Facilities:**

  ------------------------------------ ----------------------------------
  **North Chicago, IL** business plan  **Chicago, (West Side)** **IL**
  under review                         business plan under development

  **Tampa, FL** business plan under    **Chicago, (Hines) IL** business
  development                          plan under development

  **Lebanon, PA** business plan under  **Mt. Home, TN** business plan
  development                          under development

  **Augusta, GA** business plan under  
  development                          
  ------------------------------------ ----------------------------------

**Parking Facilities:**

**Chicago (Westside), IL** The VAMC is presently soliciting for a 1000
space *Parking Garage* to be financed, constructed and operated on the
VAMC campus by a private developer. In return for a long term lease and
market opportunity, the developer would provide no cost parking for VA
patients and reduced fee parking to VA employees, all at no cost to
VA**.**

**Mountain Home*,* TN** *Parking* *Structure* Business Plan under
development. Possibility of federal and state grant funding.

**St. Louis, MO** *Parking Structure* Feasibility study under
development.

**Big Springs, TX** *Parking* Lease awarded March 8, 1996 for
construction of surface parking lot for VA employees, in consideration
of an outlease of VA land to employee credit union.

**Little Rock, AR** *Parking* VAMC studying possible E-U lease to
affiliate for parking structure to meet requirements of both medical
facilities.

**Child Development Centers (CDC) - Elder Care:** Provider leases VA
land on a long term basis for use as a community child development
(elder care) center. In return, VAMC employees are guaranteed access to
such services at reduced rates**.** For example:

  -------------------------------------- --------------------------------
  **Washington, DC** completed 9/95      **West Haven, CT** CDC & Elder
                                         care, groundbreaking 12/95

  **Sepulveda, CA** pending lease        **West Los Angeles, CA** pending
  execution                              lease execution

  **Houston, TX** pending lease          **Leavenworth, KS** pending
  execution                              lease execution

  **Bay Pines, FL** pending lease        **Puget Sound (Am Lake),**
  execution                              **WA** public hearing scheduled

  **Richmond, VA** proposals being       **Hampton, VA** CDC/Elder Care
  reviewed                               under review

  **Reno, NV** public hearing scheduled  **Phoenix, AZ** public hearing
                                         held

  **Lyons, NJ** business plan under      **Lexington, KY** business plan
  development                            under development

  **Danville, IL** business plan         **Providence, RI** business plan
  underdevelopment                       under development

  **Lincoln, NE** business plan under    
  development                            
  -------------------------------------- --------------------------------

**Golf Courses:** Several VAMCs are initiating/developing various
alternative agreements to eliminate the need to use medical resources
for operation and maintenance of golf courses yet preserve their use for
therapeutic use.