By the end of this article, you should better understand the VA practice model as it relates to the practice of urology.
In a series of articles, we will examine some of the practice models available to urologists in today's dynamic health care landscape. In this first installment, we examine one of the older and more stable practice models: the Veterans Affairs system. To this end, we interviewed Lori Lerner, MD, a practicing urologist with the VA in Boston. By the end of this article, you should better understand the VA practice model as it relates to the practice of urology.
Dr. Lerner is among the nation's 300-plus VA urologists who practice in at least 100 VA facilities across the country. The VA cares for an estimated 22,658,000 veterans, and it is estimated that urology accounts for a significant portion of annual visit volume. During their training, many urologists worked in programs affiliated with a VA hospital, but the VA system also has a wide range of clinics and outpatient and inpatient facilities offering services to veterans across the United States.
Urologists practice in one of two basic practice models within the VA system: those employed by the VA and those who are independent contractors. In order to receive benefits, a urologist must be employed full time. Part-time employment is also common when more than one urologist may share a position. The VA may also create an independent contractor arrangement with a urologist, or even a group of urologists, to provide specialty coverage within one or more of their facilities. Dr. Lerner says this is more common in smaller communities. In a VA facility associated with an academic institutional relationship (university) contract, the urologist may be part of a sharing arrangement: working primarily for one entity and subcontracted to the other.
The budget of the VA (health services, veteran's benefits, and operation of the National Cemetery Administration) makes it the second largest federal government expenditure, behind the Department of Defense. Urology services in a VA unit are usually budgeted on a 3-year cycle and essentially operate like a business that receives capitated revenue; like any enterprise, they must manage salaries, supplies, and other ordinary costs, while revenue remains fixed.
The urologist employed full time in the VA system typically draws a tier 3 salary that is market based, reviewed every 2 years, embedded with a cost of living raise each year, and supplemented by performance incentives based on quality, productivity, and efficiency metrics. Employment in the VA system also brings access to a high-quality medical plan enjoyed by all federal workers and a retirement plan backed by the United States.
Dr. Lerner explains that local divisions/departments are given authority for capital spending, and there is an approval process for nonordinary expenses above a threshold ($100,000). The chain of command is often similar to a traditional medical staff, with division heads, department heads, medical directors, and opportunities for advancement and administrative responsibility; executive leadership programs are available to interested employees. For urologists who are not directly employed, contracting arrangements vary, but can include per diem rates, traditional fee for service billing, or even a capitated exclusive contract.