GAO

United States General Accounting Office

Report to the Ranking Minority Member,

Committee on Veterans’ Affairs, U.S.

Senate

April 2000 VA HEALTH CARE

Changes in Medical

Residency Slots

Reflect Shift to

Primary Care

GAO/HEHS-00-62

Page 1 GAO/HEHS-00-62 VA Medical Residency Slots

Contents

Letter 3

Appendixes Appendix I: Objectives, Scope, and Methodology 14

Appendix II: Number of VA Medical Resident Primary Care

and Specialty Slots in Academic Year 1999-2000 16

Appendix III: Percentage of Residency Slots in Primary Care

Training, by Network 18

Appendix IV: Selected VA Facility and Affiliated Medical School

Residency Slots Before and After VA Residency Realignment 20

Appendix V: Summary of Community-Based Outpatient Clinic Data

for the Six VA Facilities Visited 21

Appendix VI: Comments From the Department of Veterans Affairs 22

Appendix VII: GAO Contact and Staff Acknowledgments 24

Tables Table 1: Changes in the Number of Residency Slots Supported by VA 7

Table 2: Changes in Residency Slots at the Six Facilities Visited 8

Abbreviations

CBOC community-based outpatient clinic

UCLA University of California at Los Angeles

VA Department of Veterans Affairs

VISN Veterans Integrated Service Network
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United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-283989 Letr

April 12, 2000

The Honorable John D. Rockefeller IV

Ranking Minority Member

Committee on Veterans’ Affairs

United States Senate

Dear Senator Rockefeller:

Many changes under way in the Department of Veterans Affairs (VA) have

the potential to affect the relationship between VA medical facilities and

their affiliated medical schools. For example, VA has been reorganizing its

health care delivery system by moving more care from inpatient to

outpatient settings. It is also integrating facilities and consolidating

programs and services at health care facilities to improve efficiency, which

could potentially affect its graduate medical education program. Also, over

the last 3 years, VA has been realigning its graduate medical education

program, which involves reducing specialty residency slots while

increasing the number of primary care slots—such as those in family

practice and internal medicine.

You expressed concern that limited information is available explaining the

rationale for changes in the numbers and types of medical residency slots

and describing the effect these changes have had on the resident training

environment.1 In this context, you asked us to address the following

questions: (1) What were VA’s goals in realigning its residency program, and

did VA accomplish its goals? (2) Who initiated the changes in the number of

graduate medical education residency slots, and why? (3) What are the

views of VA facility and medical school officials on the effect of the

changes on resident training and on the potential to train residents at VA

community-based outpatient clinics? To assess residency realignment, we

met with officials from VA’s Office of Academic Affiliations, reviewed VA’s

residency realignment goals, and compared the goals with data from the

last 3 academic years. For the other questions, we visited six VA facilities

that experienced among the largest net changes in their number of

residency slots. At each facility, we met with senior management officials,

1

Residents have graduated from medical school and are undergoing clinical training to

prepare them to practice medicine independently.
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clinical service chiefs, and representatives from the affiliated medical

school(s) to determine their rationale for changes in the number of

residency slots and to obtain views about the effect the changes have had

on the training environment and on the opportunities for training at VA

community clinics. We did our work from May 1999 through January 2000

in accordance with generally accepted government auditing standards.

Additional information on our scope and methodology is included as

appendix I.

Results in Brief The changing health care environment has resulted in less demand for

specialty physicians and more demand for primary care physicians. This

shift, in turn, influenced the changes in residency slots at VA. Over the last

three academic years,2 VA realigned its graduate medical education

program and achieved its goal to train 48 percent of its residents in primary

care. VA’s strategy eliminated 251 residency slots in specialty care and

converted 714 specialty residency slots to primary care slots. These

changes reduced the number of residency slots from 8,910 to 8,659.

The major reasons for the changes in residency slots were (1) VA’s decision

to increase primary care residency slots and decrease specialty slots and

(2) medical school decisions to restructure their programs to meet

changing demands for physicians or accreditation requirements. VA

initiated the majority of changes in the residency slots at the six facilities

we visited, but these changes were consistent with the medical schools’

own initiatives to meet changing demands. VA and medical school officials

characterized the changes as generally mutually beneficial because they

were consistent with current health care practices nationally.

Changes in residency slots have not been disruptive to training, according

to VA and medical school officials at the six facilities we visited. When VA

reduced the number of residency slots, for the most part those residency

slots reappeared at other hospitals affiliated with the medical schools. In

addition, VA and medical school officials said that some training

opportunities exist at VA’s community-based outpatient clinics. However,

VA is not pursuing establishment of such slots because (1) sufficient

opportunities exist for primary care training in outpatient clinics located at

VA hospitals; (2) remote community-based clinics present a commuting

2

The academic year runs from July to June.
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problem for the residents; and (3) the physicians who would be required to

supervise and train residents at the remote clinics might not be able to

obtain faculty status at the medical schools.

Background The U.S. health care system is undergoing profound changes. Rapid

technological advances, changing economic and demographic factors, and

an emphasis on cost containment have resulted in a dramatic decrease in

inpatient care and a corresponding increase in ambulatory services.

Recognizing the need to adapt to changes occurring in the health care

environment, VA is reorganizing its health care delivery system. VA

replaced its four health care regions with 22 Veterans Integrated Service

Networks (VISN). VA’s reorganization has increased veterans’ access to

ambulatory care, emphasized primary care, and decentralized decisionmaking. To attract and retain veterans who do not live close to VA medical

facilities, VA has also established community-based outpatient clinics that

emphasize primary care.

Each of VA’s 22 networks oversees between 4 and 11 medical facilities.

Some networks have integrated facilities, a critical piece of VA’s overall

strategy to enhance the efficiency and effectiveness of health care delivery

to veterans. An integration involves restructuring clinical and

administrative services within two or more medical facilities into one

health care delivery system. Integrations are meant to allow VA to provide

the same or higher quality services to veterans at a reduced cost. As of

January 2000, networks had initiated 26 integrations involving 54 facilities.

Transforming VA’s health care delivery system from an inpatient to an

outpatient focus, increasing reliance on primary care, and consolidating

services in two or more facilities could have direct implications for VA’s

education mission—one of its four core missions.3 For example, VA’s

initiatives will increasingly involve consolidating programs or possibly

closing facilities to eliminate duplication among nearby VA facilities.

Because VA is a major source of medical training opportunities, medical

schools clearly have a vested interest in VA’s transformation.

Since 1946, VA facilities have had affiliation agreements with medical

schools. VA appoints medical school faculty as VA staff physicians so that

3

VA’s four core missions are patient care, education, research, and medical backup to the

Department of Defense in the event of a national security emergency.
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they can teach and supervise medical residents and students who are

training at VA facilities. Of VA’s 172 medical centers, 130 are affiliated with

107 medical schools. In fiscal year 1999, VA spent about $356 million for

residents’ salaries. VA is supporting 8,659 residency slots during the 1999-

2000 academic year. Annually, 33,000 residents rotate through these slots—

almost one-third of all residents trained in the United States.

These affiliations are beneficial to both VA and medical schools. Residents

provide a portion of the care to veterans at VA facilities. According to VA,

when residency slots cannot be filled, the cost of replacement by

nonphysician practitioners or fully trained physicians is greater. Residents

are taught and supervised by VA physicians who hold academic faculty

appointments, provide direct patient care, and conduct research. This

combination of patient care, education, and research makes VA positions

attractive for the recruitment and retention of highly qualified physicians.

An additional advantage is that some VA-trained residents become career

employees.

VA Residency

Realignment Goals

Have Been Met

For academic year 1999-2000, VA met its goal of increasing to 48 percent

the portion of its residents training in primary care. In 1997, VA began

reducing the number of specialty residents trained by eliminating some

slots and shifting some slots to primary care. This goal was established on

the basis of the national need to reduce the total number of resident

training slots and the number of residents trained in specialty care.

Recognizing the changing nature of health care, the Under Secretary for

Health appointed a committee to develop a strategy that would ensure that

VA’s graduate medical education program was prepared to meet present

and future health care needs.4 He asked the committee to include any

issues that might improve VA’s graduate medical education program,

including the number and types of training opportunities.

In May 1996, the Residency Realignment Review Committee recommended

that VA increase its proportion of primary care slots to 48 percent by

4

The Residency Realignment Review Committee was convened in the fall of 1995 by the

Under Secretary for Health. The Committee was made up of nationally acknowledged

experts in graduate medical education representing both VA and the private sector. The

Committee was charged with making recommendations for the possible realignment of the

graduate medical education program.
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eliminating 250 residency slots in disciplines other than primary care and

shifting 750 slots from specialty care to primary care. The Committee

defined primary care slots as internal medicine, family practice, geriatric

medicine, preventive medicine, obstetrics, and gynecology. Specialty care

was defined as those slots that provide support to VA primary care and

includes psychiatry, general and other types of surgery, cardiology and

other subspecialties of internal medicine, pathology, and radiology (see

app. II for a list of primary care and other specialties). The Committee

suggested that its recommendations be implemented over a 3-year period

ending with academic year 1999-2000. VA accepted the Committee’s

recommendations.

Table 1 shows the changes VA made to attain its goal of having 48 percent

of its residency slots in primary care. This reduced the number of residency

slots to 8,659 systemwide. See appendix III for a list of changes by network.

Table 1: Changes in the Number of Residency Slots Supported by VA

Note: Fifty-eight VA facilities designated 281 medical subspecialty and psychiatry residency slots as

primary care because residents spent a portion of their rotations providing primary care. This

accounted for 3 percent of the total 8,659 slots.

Baseline

academic

year 1995-96

Academic year

Change

from

baseline

1997-98 1998-99 1999-2000 year

Total VA-supported

residency slots 8,910 8,848 8,721 8,659 -251

Total VA-supported

residency slots in

primary care 3,442 3,655 3,813 4,156 +714

Total VA-supported

residency slots in

specialty care 5,468 5,193 4,908 4,503 -965

Percentage of VAsupported

residents in

primary care 39 41 44 48 +9
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Changing Health Care

Environment

Influenced Shifts and

Reductions in VA

Residency Slots

The changing health care environment, such as the increased emphasis

placed on primary care, was the main reason for the shifts and reductions

in the 207 residency slots at the six facilities we visited. VA’s residency

realignment effort increased residency slots in primary care and reduced

the number of specialty slots, and in the meantime, the affiliated medical

schools decided to restructure their programs to meet changing demands

for physicians or accreditation requirements.

To understand the reasons for the changes in the number of residency slots,

we visited six VA facilities that had experienced among the largest net

changes in the number of slots—Albany, New York; Albuquerque, New

Mexico; Gainesville, Florida; Muskogee, Oklahoma; Philadelphia,

Pennsylvania; and West Los Angeles, California. During our facility visits,

we obtained information on the specific reasons for each change and

whether VA or the medical school initiated the change.

As shown in table 2, the six VA facilities initiated more changes that added

residency slots than the medical schools did because of VA’s desire to

increase the number of primary care residents trained. On the other hand,

the medical schools initiated changes that reduced residency slots more

often than VA did.

Table 2: Changes in Residency Slots at the Six Facilities Visited

Of the 120 changes in residency slots that VA initiated, 24 increased the

number of primary care resident slots and 49 decreased the number of

specialty residency slots. Various reasons accounted for the other 47 slots

affected. For example, the VA facility in Albuquerque obtained 12 residency

slots in general internal medicine from another VA facility within the same

network. This change was made because an affiliated medical school, the

Texas Tech University Medical School, decided to reduce the size of its

Residency

slots

added

Residency

slots

decreased

Total

residency

slots affected

Percentage of

total change

VA-initiated change 58 62 120 58%

Medical school-initiated

change 14 73 87 42%

Total changes for six facilities 72 135 207 100%
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general internal medicine program at the VA facility in Amarillo, Texas. VA

changed the remaining 35 residency slots for various reasons, including

adding new residency programs, reducing existing residency programs, and

the changing patient workload demands.

When medical schools initiated changes in residency slots, the vast

majority of the changes resulted in decreases in the number of residency

slots. Seventy-three of the 87 changes in residency slots shown in table 2

resulted in such reductions. Medical schools decided to reduce residency

slots mainly because of restructuring decisions or accreditation

requirements. While medical schools did not usually initiate large changes

in the number of residency slots, this was the case at two of the locations

that we visited.

• In the first case, one of the two medical schools affiliated with the VA

facility in Philadelphia, MCP Hahnemann University School of Medicine,

discontinued its affiliation with VA after a merger with another school

and subsequent assessment of its patient workload and the number of

residents it could support. This resulted in a decrease of 24 residency

slots at VA in four different resident training programs.

• In the second case, the University of Oklahoma College of MedicineTulsa, which is affiliated with the VA facility in Muskogee, was

experiencing accreditation problems with some of its residency

programs. Because the medical school was affiliated with four hospitals,

it decided to consolidate its residency programs so that it could deal

with fewer hospitals. Since the Muskogee facility was located 45 miles

away from the school, the school pulled back 17 residency slots—13

slots in general internal medicine and family practice and 4 general

surgery slots.

The remaining 46 changes in residency slots initiated by the medical

schools resulted for a variety of reasons. For example, the medical schools

made changes because of difficulty in utilizing and filling residency slots in

certain specialties or decisions to downsize certain specialties. Two

medical schools, for example, reduced 10 residency slots in anesthesiology

because of difficulty recruiting residents. Other reasons included changes

in patient workload and adding new resident training programs. For

example, a medical school relocated a training slot in rheumatology to

another affiliate because the workload at VA was not adequate to support

the number of residents assigned. Another medical school increased the

number of slots in cardiology to build its program in that specialty.
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VA’s Resident Training

Has Not Been Impaired

The shifting of residency slots from specialty to primary care and the

elimination of specialty slots have not been disruptive to training,

according to VA and medical school officials at the locations we visited.

When VA initiated changes in residency slots, it was generally done in

collaboration with the medical schools because the medical schools have

been under pressures similar to those VA has experienced to meet changing

health care demands.

Most VA and medical school officials we interviewed said that while the

elimination of some slots and the shifting of others had sometimes been

difficult to implement, the realignment did not adversely affect training of

the remaining residents or the accreditation of residency programs. In most

cases, when VA reduced slots, the medical schools relocated them to their

other affiliates. Therefore, the medical schools’ residency programs

generally maintained their size (see app. IV for a comparison of the number

of medical schools’ residency slots before and after VA’s residency

realignment initiative).

Medical schools were under similar pressures to change residency

programs while VA was realigning residency slots. For example, some

medical schools reduced specialty residency programs because of state

legislation to increase the number of residents trained in primary care.

According to the National Conference of State Legislatures, 11 states

passed legislation in the early 1990s to have medical schools increase their

training of primary care physicians. Seven of those state laws required the

schools to direct at least 50 percent of their graduates into primary care.5

The University of California at Los Angeles (UCLA) School of Medicine,

which is affiliated with the VA facility in Los Angeles, was affected by such

legislation. In 1992, the California legislature passed a bill that required

medical schools to increase their primary care residency slots to 50 percent

of the total number or lose up to $8 million in state funding. Although this

legislation was subsequently vetoed, in a 1994 memorandum of

understanding with the state of California, UCLA agreed to increase its

percentage of residents in primary care to 60 percent over a 10-year period.

Thus, when the VA facility in Los Angeles initiated increases in primary

care residency slots and decreases in specialty care slots, it actually helped

5

See Carol S. Weissert, Ph.D, and Susan Silberman, Holding Medical Schools Accountable: A

Study of State Legislative Action and Implementation, report submitted to the Robert Wood

Johnson Foundation (Feb. 28, 1998).
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UCLA meet its goal. Similar legislation affected schools elsewhere, such as

the Albany Medical College, which is affiliated with the Albany VA facility

in New York.

According to medical school and VA facility officials, most residents have

remained satisfied with their education experience. Medical school

officials told us that on the basis of surveys and interviews regarding VA

rotations, there has been no change in residents’ satisfaction levels.

Residents like their VA rotations and, in some cases, consider them their

best experiences. In addition, medical schools value the opportunities VA

rotations afford their residents. VA provides education opportunities that

residents are not always able to get at other affiliates, such as working with

a larger population of patients who are older and have multiple and

advanced diseases. Furthermore, VA officials told us that some residents

prefer VA rotations because they (1) have more independence and greater

responsibility, (2) believe the teaching atmosphere is better at VA facilities

because VA physicians spend more time with the residents, and (3) spend

more time with patients.

While most VA and medical school officials did not believe that the training

environment had been impaired by VA’s residency realignment, some cited

examples of how the environment had been affected. For example, the

decrease in subspecialty residency programs has resulted in some loss of

interaction between specialists and primary care residents. In addition, VA

and medical school officials told us that reductions in slots will mean that

some residents will miss the opportunity to treat patients who are older

and have multiple and advanced diseases.

Opportunities for

Training at

Community-Based

Outpatient Clinics

VA and medical school officials agreed that some training opportunities are

available at VA’s community-based outpatient clinics (CBOC). CBOCs differ

from traditional freestanding VA outpatient facilities in that they provide

primary care to veterans and frequently use private providers who contract

with VA. The type of care veterans receive at these clinics is comparable to

that available at a private physician’s general practice office. The CBOCs

associated with VA facilities we visited are located from 5 to 240 miles

away.

Residents were not being trained at any of the 32 CBOCs associated with

the six facilities we visited. (See app. V for specific information regarding

the CBOCs at these facilities.) Moreover, VA has no plans to train residents

at these locations. VA officials told us they are not using CBOCs for
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resident training because (1) sufficient opportunities for primary care

training exist in outpatient clinics located at VA hospitals; (2) CBOCs

located far from the hospital present a commuting problem for the

residents; (3) physicians who would be required to supervise and train

residents at the remote clinics might not be able to obtain faculty status at

the medical schools; and (4) the variety of education experiences residents

would receive at CBOCs is limited, so residents would need to train at

additional locations.

Agency Comments In commenting on a draft of this report, VA concurred with its content. We

made minor revisions on the basis of VA technical comments, as

appropriate. VA’s comments are included in appendix VI.

We are sending copies of this report to the Honorable Togo West, Secretary

of Veterans Affairs, and other congressional committees with an interest in

this issue. We will also make copies available to others on request.

If you have any questions about this report, please call me at (202) 512-7101

or Walter Gembacz at (202) 512-6982. Other major contributors to this

report are listed in appendix VII.

Sincerely yours,

Stephen P. Backhus

Director, Veterans’ Affairs and

Military Health Care Issues
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Appendix I

Objectives, Scope, and Methodology ApApenednxidexiIs

The Ranking Minority Member of the Senate Committee on Veterans’

Affairs expressed concern that there was limited information available

explaining the rationale for changes in the numbers and types of residency

slots or describing the effect these changes have had on the resident

training environment. In this context, he asked us to address the following

questions: (1) What were VA’s goals in realigning its residency program, and

did VA accomplish its goals? (2) Who initiated the changes in the number of

graduate medical education residency slots, and why? (3) What are the

views of VA facility and medical school officials on the effect of the

changes on resident training and on the potential to train residents at VA

community-based outpatient clinics?

To determine whether VA’s realignment of its residency program

accomplished its goals, we met with officials from the Veterans Health

Administration’s Office of Academic Affiliations, reviewed VA’s residency

realignment goals, and compared the goals with the latest available data on

residency slots. We examined numbers of residency positions for academic

years 1995-96 through 1999-00, the period during which VA implemented its

residency realignment.

To address who initiated the changes and why, we visited six VA facilities

that experienced among the largest net changes in the number of residency

slots. In selecting the facilities, we considered the number of residency

slots supported by VA. We selected facilities from six different Veterans

Integrated Service Networks (VISN) and, among them, selected two

integrated facilities. The six facilities selected were located in Albany, New

York (VISN 2); Albuquerque, New Mexico (VISN 18); Gainesville, Florida

(VISN 8);1 Muskogee, Oklahoma (VISN 16); Philadelphia, Pennsylvania

(VISN 4); and West Los Angeles, California (VISN 22).2

At each facility, we interviewed senior management officials and clinical

service chiefs at VA medical centers and representatives from the affiliated

medical schools to determine the reasons for increases or decreases in the

number of residents trained in a specific specialty. For facilities where the

residency positions were decreased, we determined whether the medical

schools relocated the slots to affiliates or eliminated the slots.

1

This facility, which is part of the VA North Florida/South Georgia Health Care System and

also includes the Lake City VA Medical Center, was integrated in 1997.

2

This facility, which is part of the Greater Los Angeles Health Care System and also includes

the Sepulveda and Los Angeles Outpatient Clinics, was integrated in 1998.
Appendix I

Objectives, Scope, and Methodology

Page 15 GAO/HEHS-00-62 VA Medical Residency Slots

To obtain views about the effect of changes in residency slots on the

graduate medical education training, including opportunities for training

residents at VA community-based outpatient clinics, we interviewed senior

management officials and clinical service chiefs at VA facilities and

representatives from the affiliated medical school(s).
Page 16 GAO/HEHS-00-62 VA Medical Residency Slots

Appendix II

Number of VA Medical Resident Primary Care

and Specialty Slots in Academic Year 1999-

2000 ApendxiI

Type of slot Number of slots

Primary care

Family practice 147

Geriatric medicine 170

General internal medicine 3,476

Gynecology 21

Obstetrics/gynecology 7

Preventive medicine 38

Specialty care

Addiction psychiatry 1

Allergy and immunology 9

Anesthesiology 187

Colon and rectal surgery 1

Cardiovascular disease 266

Critical care 7

Dermatology 140

Diagnostic radiology 262

Emergency medicine 6

Endocrinology and metabolism 64

Geriatric psychiatry 28

Gastroenterology 180

Hematology 16

Hematology/oncology 107

Infectious diseases 81

Nephrology 89

Neurology 255

Neurological surgery 57

Nuclear medicine 29

Occupational medicine 17

Ophthalmology 237

Orthopedic surgery 216

Otolaryngology 162

Pathology 198

Pulmonary/critical care 159

Plastic surgery 47

Physical medicine and rehabilitation 189

Continued
Appendix II

Number of VA Medical Resident Primary Care

and Specialty Slots in Academic Year 1999-

2000

Page 17 GAO/HEHS-00-62 VA Medical Residency Slots

Note: Because the numbers of residency slots for each specialty were rounded, the number of slots

totals to 8,660 instead of 8,659; VA actually has a total of 8,659.2 slots.

Psychiatry 778

Radiation oncology 24

Rheumatology 48

General surgery 706

Thoracic surgery 49

Urology 179

Vascular surgery 7

Total 8,660

Type of slot Number of slots

Continued from Previous Page
Page 18 GAO/HEHS-00-62 VA Medical Residency Slots

Appendix III

Percentage of Residency Slots in Primary Care

Training, by Network ApendxiI

P

Academic year 1995-96

Network

Percentage of

primary care

slots

Number of

primary care

slots

Total number

of residency

slots

1 36 192.7 530.4

2 35 91.4 261.9

3 35 220.0 621.0

4 48 157.5 330.7

5 43 102.5 236.5

6 42 153.0 368.3

7 39 177.0 452.0

8 34 191.0 558.5

9 42 232.5 553.5

10 37 97.0 259.0

11 40 130.5 323.5

12 38 256.0 679.5

13 42 91.0 214.7

14 41 82.7 200.0

15 39 134.0 347.1

16 35 242.0 696.3

17 36 124.0 340.0

18 49 148.4 303.3

19 39 89.3 226.3

20 45 118.3 261.3

21 35 135.0 388.5

22 36 276.0 757.6

National 39 3,442.0 8,910.0
Appendix III

Percentage of Residency Slots in Primary

Care Training, by Network

Page 19 GAO/HEHS-00-62 VA Medical Residency Slots

Academic year 1999-2000 1995-96 versus 1999-2000

Percentage of

primary care slots

Number of primary

care resident slots

Total number of

residency slots

Percentage change

in primary care slots

Change in number

of primary care slots

Change in total

number of residency

slots

45 230.8 515.4 9 38.1 -15.0

42 104.2 245.9 7 12.8 -16.0

46 270.8 587.5 11 50.8 -33.5

56 178.5 320.9 8 21.0 -9.8

54 131.7 246.0 11 29.2 +9.5

48 168.3 348.8 6 15.3 -19.5

49 213.1 438.4 10 36.1 -13.6

45 246.6 546.5 11 55.6 -12.0

50 262.9 528.3 8 30.4 -25.2

50 126.1 253.9 13 29.1 -5.1

50 161.0 319.0 10 30.5 -4.5

47 310.2 656.8 9 54.2 -22.7

48 93.9 197.6 6 2.9 -17.1

52 100.7 194.5 11 18.0 -5.5

48 162.0 339.0 9 28.0 -8.1

45 309.9 682.1 10 67.9 -14.2

46 154.6 333.0 10 30.6 -7.0

58 176.0 304.7 9 27.6 +1.4

50 117.6 233.9 11 28.3 +7.6

55 148.4 268.8 10 30.1 +7.5

44 166.5 379.7 9 31.5 -8.8

45 322.6 718.5 9 46.6 -39.1

48 4,156.0 8,659.0 9 714.0 -251.0
Page 20 GAO/HEHS-00-62 VA Medical Residency Slots

Appendix IV

Selected VA Facility and Affiliated Medical

School Residency Slots Before and After VA

Residency Realignment ApendxiIV

Notes: Although the number of residency slots at the Albany Medical College went down from

academic year 1995-96 to 1999-2000, VA did not initiate any of the reductions.

Although the number of residency slots at the University of Florida went down from academic year

1995-96 to 1999-2000, VA initiated seven of these reductions and only one of these was due to VA’s

residency realignment effort.

a

Integration of Gainesville facility with Lake City facility.

b

Integration of West Los Angeles facility with Sepulveda and Los Angeles outpatient clinics.

Percentage of

residents in primary

care slots VA residency slots

Total number of

residency slots

associated with medical

school

VA facility/affiliated medical school 1995-96 1999-2000 1995-96 1999-2000 1995-96 1999-2000

Albany/Albany Medical College 37 43 81.4 66.9 419 381

Albuquerque/University of New Mexico 36 54 99.8 112.9 424 439

Gainesville/University of Floridaa 27 37 122.0 110.0 591 547

West Los Angelesb 35 46 328.6 322.0

University of California LA 1,900 1,900

University of Southern California 1,000 1,000

Muskogee/University of Oklahoma 81 100 21.0 4.0 159 144

Philadelphia 42 43 123.0 92.2

University of Pennsylvania 783 938

MCP Hahnemann University 703 587
Page 21 GAO/HEHS-00-62 VA Medical Residency Slots

Appendix V

Summary of Community-Based Outpatient

Clinic Data for the Six VA Facilities Visited ApendxiV

a

Integration of Gainesville facility with Lake City facility.

b

Integration of West Los Angeles facility with Sepulveda and Los Angeles outpatient clinics.

Location of VA facility visited

Number of community-based

outpatient clinics

Range of distance between

clinics and VA facility (in miles)

Are community-based

clinics utilized for training

residents?

Albany 10 5 to 205 No

Albuquerque 5 139 to 240 No

Gainesvillea 5 35 to 180 No

West Los Angelesb 8 5 to 192 No

Muskogee 2 50 to 65 No

Philadelphia 2 45 to 60 No
Page 22 GAO/HEHS-00-62 VA Medical Residency Slots

Appendix VI

Comments From the Department of Veterans

Affairs ApendxiVI

Note: A GAO comment

supplementing those in

the report text appears at

the end of this appendix.

Now on p. 6.

See comment 1.
Appendix VI

Comments From the Department of Veterans

Affairs

Page 23 GAO/HEHS-00-62 VA Medical Residency Slots

The following is GAO’s comment on the Department of Veterans Affairs’

letter dated March 13, 2000.

GAO Comment 1. No revision. Although we did not mention the Residency Realignment

Review Committee by name, we gave prominence to the realignment of the

graduate medical education program in the opening paragraph and in the

results in brief of this report.
Page 24 GAO/HEHS-00-62 VA Medical Residency Slots

Appendix VII

GAO Contact and Staff Acknowledgments ApendxiVI

GAO Contact Walter Gembacz, (202) 512-6982

Staff

Acknowledgments

The following staff made key contributions to this report: John Borrelli,

Marcia Mann, Sigrid McGinty, Maria P. Vargas, and Stefanie Weldon.

(406178) Letr
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