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Research Letter | Association of VA Surgeons

The Use of Joint Incentive Funding to Create a Department of Veterans Affairs–Department of Defense Vascular Surgery Program FREE

Robert E. Noll Jr, MD1,2; B. Zane Atkins, MD2; John Carson, MD1; James Sampson, MD2; David Dawson, MD1,2; Scott Hundahl, MD1; W. Darrin Clouse, MD2
[+] Author Affiliations
1Division of Vascular Surgery, Sacramento VA Medical Center, Mather, California
2Division of Vascular Surgery, David Grant Medical Center, Travis Air Force Base, California
JAMA Surg. 2015;150(3):272-274. doi:10.1001/jamasurg.2014.1768.
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Published online

Vascular surgery is critical to military management of wartime casualties and, at the same time, to aging veterans with chronic vascular disorders.1,2 A federal system of collaboration in a restrictive health care environment can expand and enhance the provision of vascular care. We report our experience in developing and sustaining a joint effort between the Department of Veterans Affairs (VA) and the Department of Defense (DOD) to create a vascular surgery program using joint incentive funding (JIF).3

We provide a review of a successful JIF program, the first to combine the vascular and endovascular services of the US Air Force and VA Medical Centers to offer comprehensive and additive care as one component of a multidisciplinary, JIF-funded Heart, Lung, and Vascular Center. Grant funding is obtained through a competitive process and utilizes fiscal resources from both departments to support concept proposals. Investment funding for personnel, facility improvement, and equipment is provided for 2 years. Following-year funding is based on the volume of patient care at program onset, rewarding early clinical productivity.

Earnings represent VA-DOD JIF program cost avoidance. The cost difference between JIF-supported care and treatment received in community health care systems is calculated using Current Procedural Terminology codes, diagnosis related groups, and a set Civilian Health and Medical Program of the Uniformed Services Maximum Allowable Charge.4 Return on investment is the difference between JIF investment and earnings.

The annual volume of vascular surgery cases related to the JIF proposal increased steadily over 3 years (from 222 cases in the first year, to 325 cases in the second year, to 352 cases in the third year) (Figure 1). This included 53 aortic and 405 endovascular procedures. Similar increases in outpatient visits to the Heart, Lung, and Vascular Center (from 648, to 732, to 1064 visits) and in noninvasive vascular laboratory investigations (from 1288, to 1399, to 1698 investigations) occurred. The vascular surgery workload at the Heart, Lung, and Vascular Center augmented an existing VA Medical Center vascular contingent with growth in combined cases (from 541, to 595, to 721 cases), outpatient visits (from 2437, to 2767, to 3105 visits), and vascular laboratory investigations (from 3526, to 3579, to 3889 investigation). The investment in the JIF program was $1.3 million (for personnel and equipment). Cumulative earnings tallied $9.88 million with a combined return on investment of $8.58 million (Figure 2). Additional DOD benefits included clinical currency and readiness for deployable assets; uninterrupted, sophisticated home-based patient service during war; and the establishment of a unique US Air Force vascular surgery graduate medical education program.

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Figure 1.
Annual Cumulative Number of Vascular Surgery Cases at the Heart, Lung, and Vascular Center
Graphic Jump Location
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Figure 2.
Cumulative Joint Incentive Funding Investment, Earnings, and Return on Investment
Graphic Jump Location

The detailed planning and implementation demanded by competitive JIF grant processes facilitated the creation of a new, joint VA-DOD vascular surgery program that has proven to be financially and clinically desirable. From the DOD perspective, federal programs such as this promote readiness and currency skills for military personnel, maintain services during operations, and support the vascular surgery graduate medical education program. From the VA perspective, such programs provide a sophisticated, cost-effective capacity to meet demand while simultaneously serving the VA’s educational mission. Previous regional JIF endeavors include programs in nephrology, neurosurgery, and cardiothoracic surgery with returns on investment ranging from 10% to 284%.

The challenges to the development of the program have been the implementation of minimally integrated electronic medical record systems and the coordination of vascular care over a large geographical area. At the same time, encouraging clinical and financial outcomes led to additional VA-DOD collaborations. Specifically, an approved JIF Triage and Federal Care Initiative established an administrative-clinical management hub for prompt triage consultations and as a regional transfer center. The JIF-hired clinical specialists are able to access dual-system information and electronic health records with adjacent VA and DOD computers. This ensures access to care goals with prompt assignment to facility and health care provider, and assists in returning beneficiaries in community hospitals back to federal facilities.

The joint VA-DOD vascular surgery program successfully used shared personnel, facilities, and resources to care for patients in VA and DOD health care systems. The benefits of JIF have been substantial, with considerable fiscal savings for the federal government. Importantly, collaboration has provided our nation’s veterans and military personnel with improved access to complex vascular and endovascular surgical care.

Corresponding Author: Robert E. Noll Jr, MD, Division of Vascular Surgery, Sacramento VA Medical Center, 10535 Hospital Way, Mather, CA 95655 (robert.noll@va.gov).

Published Online: January 21, 2015. doi:10.1001/jamasurg.2014.1768.

Author Contributions: Dr Noll had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Noll, Carson, Sampson, Hundahl, Clouse.

Drafting of the manuscript: Noll, Hundahl.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Noll.

Administrative, technical, or material support: Noll, Atkins, Carson, Sampson, Dawson, Clouse.

Study supervision: Noll, Atkins, Dawson, Hundahl, Clouse.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 6, 2014; New Haven, Connecticut.

Rich  NM, Rhee  P.  An historical tour of vascular injury management: from its inception to the new millennium. Surg Clin North Am. 2001;81(6):1199-1215.
PubMed   |  Link to Article
Fox  CJ, Gillespie  DL, O’Donnell  SD,  et al.  Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-644.
PubMed   |  Link to Article
Bob Stump National Defense Authorization Act for Fiscal Year 2003, 38 USC §8111 (2006).
Tricare Management Control and Financial Studies Division. VA-DoD resource sharing billing for inpatient services. Military Health System website. http://www.tricare.mil/ocfo/mcfs/ubo/billing.cfm. Accessed May 21, 2014.

Figures

Place holder to copy figure label and caption
Figure 1.
Annual Cumulative Number of Vascular Surgery Cases at the Heart, Lung, and Vascular Center
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Cumulative Joint Incentive Funding Investment, Earnings, and Return on Investment
Graphic Jump Location

Tables

References

Rich  NM, Rhee  P.  An historical tour of vascular injury management: from its inception to the new millennium. Surg Clin North Am. 2001;81(6):1199-1215.
PubMed   |  Link to Article
Fox  CJ, Gillespie  DL, O’Donnell  SD,  et al.  Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-644.
PubMed   |  Link to Article
Bob Stump National Defense Authorization Act for Fiscal Year 2003, 38 USC §8111 (2006).
Tricare Management Control and Financial Studies Division. VA-DoD resource sharing billing for inpatient services. Military Health System website. http://www.tricare.mil/ocfo/mcfs/ubo/billing.cfm. Accessed May 21, 2014.

Correspondence

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