The Harmful Impact to Veterans, the Medical Profession and the Community if the San Francisco VA Medical Center Is Closed
Published May 20, 2019
At an April 10, 2019 Senate Committee on Veterans’ Affairs hearing, Veterans Health Administration (VHA) Executive-in-Charge Richard Stone, MD was asked about the criteria VA will use when deciding whether to close or improve VHA facilities. In his response, Dr. Stone singled out the San Francisco VA Medical Center (SFVAMC), stating that in “San Francisco we have a beautiful site on the top of a mountain but there’s not a veteran in San Francisco in that area. They have to drive about two hours to get to us. Are we in the right location?” This official remark, which he reiterated to the COVER Commission a week later, seems to signal that VHA leadership is seriously considering the closure of the SFVAMC at its Fort Miley campus.
Discussions about the future of the SFVAMC as well as other VHA facilities is extremely relevant today because the VA MISSION Act of 2018 established an Asset and Infrastructure Review Commission which will reevaluate VHA facility closure/expansion. It is imperative that decisions of closure/expansion be based on a comprehensive and accurate assessment of the ramifications of its recommendations. Likewise, Congress, veterans service organizations, and municipal and state political representatives must have thorough information when considering the need for – or loss of – critical healthcare services and institutions.
The current document analyzes the care provision, research, training and financial consequences of the loss of the SFVAMC. It presumes that any future campus relocation would establish an outpatient VHA clinic elsewhere, and thus focuses on the impact of eliminating SFVAMC inpatient and emergency room (ER) services.
It should be noted that our analysis has far broader implications than for just the San Francisco facility. The issues we outline below in terms of the losses faced by patients, the impacts on teaching and research, and the economic consequences of facility closure decisions apply to all VHA medical centers nationwide, especially academically-affiliated ones.
As the nation debates the future of its largest and only publicly funded, fully integrated healthcare system, it is critical to understand the vital role these medical centers play and the breadth and depth of the services they deliver. Because VA leadership seems to be presenting inaccurate facts about the role of its medical centers, it is critical to set the record straight so that decisions made by the Asset and Infrastructure Review Commission are based on the facts. We recommend that all VHA medical centers assemble those facts and make them publicly available.
Closure of the SFVAMC would be deleterious to the many veterans who, in fact, live in and around San Francisco. It would be harmful to non-veterans as well. That’s the case for the following eight reasons:
The residency and fellowship training programs at the SFVAMC would be decimated and lose UCSF support in most departments.
There would be fewer physicians in the local community who treat veterans and the non-veteran public.
SFVAMC will lose its best recruitment avenue for physicians and other healthcare professionals.
The world renowned SFVAMC research program would collapse.
Veterans would increasingly be seen by private sector providers who lack the expertise to adequately identify or treat veteran-specific conditions.
Expanded use of inpatient care at non-VA facilities would drain funds from other parts of the VHA system.
Delays for emergency room and inpatient care in the Bay Area would increase for both veterans and non-veterans.
In the event of an earthquake or other emergency, there will be fewer emergency room and inpatient beds available.
SFVAMC Inpatient Utilization
Number of inpatient beds = 244 (including 120 in Community Living Center)
Number of inpatient admissions = 5,235
Average daily census = 204; Average occupancy rate = 80%
The closure of the San Francisco VA Medical Center inpatient and ER services would have devastating impacts on care of veterans, trainee education, healthcare research, community provider expertise, the local economy, emergency preparedness and VHA’s budget. Similar consequences could be expected with the closure of any other nationwide VHA medical center with an academic affiliation. The issues remain the same no matter where the facility is located.
SFVAMC has historically attracted superlative clinicians, trainees and researchers. Veterans are the chief beneficiary of their pioneering work and care. Most SFVAMC employees report that the close ties with UCSF, as well as the inherent mission driven nature of their work, are what they find so fulfilling. It is critical to note that Dr. Stone’s statements about the possible closure of the SFVAMC campus have already had adverse impact on workforce morale. The remarks have created uncertainty and financial insecurity among employees.
A firm statement is needed from VHA leadership of the assured longevity of the Fort Miley campus. Anything short of this increases the likelihood that current employees will seek work elsewhere and the medical center will be less able to recruit prospective employees and trainees.
Closure Impact on Training of Medical/Healthcare Professionals
The SFVAMC has been affiliated with the University of California, San Francisco (UCSF) School of Medicine for 60 years. There are 47 separate UCSF residency and fellowship training programs housed at the SFVAMC, plus approximately 20 training programs for other health professions.
The VHA funds 189 full-time equivalent UCSF medical residency and fellow positions annually (distributed among over 800 residents/fellows spending part of their training at the SFVAMC facility.) Most of the training occurs on inpatient units. It is estimated that the closure of SFVAMC inpatient services would reassign ~19 of those training positions within Ambulatory Care services and the remaining ~170 would be eliminated.
The average SFVAMC resident/fellow’s stipend plus benefits is approximately $100,000. For each stipended position, VA Central Office provides an additional $80,000 to the SFVAMC for education program expenses, which helps defray medical center operating costs.
In addition to residents and fellows, other UCSF trainees, such as medical students, nurses, nurse practitioners and pharmacy residents rotate part or full time at the SFVAMC.
If there were no SFVAMC inpatient services, almost all of the 47 UCSF residency and fellowship training programs at the SFVAMC would be discontinued. That’s because the required inpatient rotations would not be available and the core funding would end. The programs include: epilepsy, gastroenterology, geriatric medicine, hematology/oncology, hospice/palliative medicine, infectious disease, internal medicine, interventional cardiology, nephrology, neuromuscular medicine, nuclear medicine, ophthalmology, orthopedic surgery, pain otolaryngology, medicine, anatomic pathology, plastic surgery, psychiatry, psychosomatic medicine, pulmonary disease, radiology, rheumatology, sleep medicine, general surgery, thoracic surgery, urology.
Local private sector medical facilities do not have resources to start their own medical / surgical training programs.
Closure Impact on the Availability of Doctors Providing Healthcare in the Bay Area
UCSF is a seedbed for training the next generations of doctors. Each year, more than a third of the 470 graduating UCSF residents/fellows settle in the Bay Area to live and work. As of 2017, 7,037 former UCSF residents/fellows were living in the Bay Area.
A loss of 170 UCSF graduating physicians every year would incrementally and significantly reduce the number of physicians in the community to treat veterans and the public at large.
Closure Impact on Recruitment of a Veteran-Centric Healthcare Workforce
Educational programs are a critical mechanism for the recruitment of VHA health professionals. Positive experiences of treating veterans as well as being mentored by world renowned experts in veterans’ healthcare issues is, for a substantial number of trainees, the biggest determinant in their decision to seek VHA employment. Roughly 60% of current VHA physicians (and even higher percentages of other professions such as optometry) participated in VHA training programs.
Up to 800 fewer residents/fellows, plus hundreds of medical students and other health professional trainees would no longer train at the SFVAMC yearly. SFVAMC will lose its single best recruitment tool, whether for inpatient or outpatient positions.
Closure Impact on Research on Veterans
With over $79 million annually in grants, SFVAMC has the largest funded research portfolio in the VHA. It is one of the few medical centers in the world equipped for studies using both research-grade whole-body magnetic resonance imaging (MRI) and spectroscopy and is the site of VA’s National Center for the Imaging of Neurodegenerative Diseases. The SFVAMC has a unique partnership with the DoD to study the basic neuroscience and neuroimaging of combat-related brain and spinal cord injuries, posttraumatic stress disorder (PTSD), fracture/ polytrauma, and other neurological combat-related injuries and predictors of injuries of war fighters. Other areas of cutting-edge study include rehabilitation after stroke and traumatic brain injury, Parkinson’s Disease, fracture repair, heterotopic ossification after polytrauma, prostate cancer, tinnitus, oncology, hypertension, stroke, cardiovascular disease, breast cancer, musculoskeletal disorders, mental health and substance use disorders. Over 800 active research projects are currently being conducted at SFVAMC.
SFVAMC has many other nationally recognized clinical programs with research embedded including: the Parkinson’s Disease Research, Education, and Clinical Center, Hepatitis C Resource Center; Mental Illness Research and Education Clinical Center, the Western Pacemaker and AICD Surveillance Program, Geriatrics Workforce Enhancement Program/Optimizing Aging Collaborative, Rheumatology Training Grant, HRSA Occupational & Environmental Medicine Residency Training Enhancement, and Patient-Centered Scalable National Network for Effectiveness Research (PCORI).
SFVAMC has six National Centers of Excellence (in which research is one of the pillars) in the areas of Epilepsy Treatment, Cardiac Surgery, PTSD, HIV, Renal Dialysis and Primary Care Education.
All of these research programs lead to healthcare improvements that benefit veterans (especially those with service-connected conditions) and non-veterans alike.
SFVAMC research is founded on its inpatient services, and if they are eliminated, the UCSF affiliation would collapse. The ability to collaborate across institutions would cease. SFVAMC would never again be able to recruit researchers, and current faculty would not be replaced as they retired. Postdoctoral research fellows would go elsewhere.
Closure Impact on the Quality of Clinical Care Provided to Veterans
VHA healthcare settings provide the best (and only) environment to receive a comprehensive education and proficiency in treating veteran specific issues. Veterans are at higher risk for particular conditions, including combat related injuries (e.g., gunshot, blast, and shrapnel injuries), traumatic brain injury, heterotopic ossification, musculoskeletal injuries, spinal cord injury, toxic exposures, PTSD, military sexual trauma and suicide. Not only do VHA trained personnel know how to treat these conditions, they know which potential sources to investigate. For example, a non-VA practitioner is less likely to explore PTSD as the cause of chronic insomnia or the impact of traumatic brain injury on mood and decision-making. Non-VA practitioners would be less likely to know that a particular condition – asthma, prostate cancer, type 2 diabetes– may be the result of toxic exposures, including Agent Orange, contaminated water or burn-pits. They may, therefore, order inappropriate diagnostic tests, misdiagnose or ineffectively treat these problems and fail to collect information on their occurrence.
Social workers engage in systematic planning for veterans who are discharged after a SFVAMC inpatient stay. They connect patients to veteran-specific follow up resources, including VA and other community resources that provide home health services, legal services, transportation, community living and housing. Such wrap-around services help mitigate homelessness and other social determinants of disease progression and prevalence of suicide.
The SFVAMC has world class geriatric services that are in short supply in the private sector. For example, its Behavioral Education and Support Team (BEST) is a national prototype helping nurses and other inpatient staff deal with patients with dementia whose aggressive behavior makes it extremely difficult to find placements and thus free up needed inpatient beds for other patients.
The loss of SFVAMC training programs means that a substantial number of private sector providers would not have the expertise to adequately identify military-specific conditions.
Veterans would suffer not only because of a failure to identify and treat these critical conditions, they would not be informed about the need to add their names to registries and may be deprived of opportunities to receive compensation. No matter how well intentioned these providers, veterans may be harmed because of lack of relevant expertise.
Veterans being discharged from the Community Care Network (CCN) inpatient facilities would not receive the kind of VHA social work expertise that links them to VA wraparound resources.
SFVAMC’s BEST program, Community Living Center nursing home and team-based Acute Care for the Elderly (ACE) unit, among other programs, would vanish. Veterans would lose the complex expertise specifically developed to help them move through the aging process.
Availability of local (and national) medical expertise would decline for conditions for which SFVAMC is renowned, including:
MRI-guided deep brain stimulation surgery
transcatheter aortic valve replacement procedures
shoulder surgery using 3-D printing
neuroendovascular surgery for acute stroke
Mohs surgery for skin cancer
imaging of neurodegenerative diseases
sleep disorder treatment combining pulmonary, dental and ENT
Closure Impact on Access to Clinical Care for Veterans
There is little to no room in the community to absorb an influx of veterans. Emergency Rooms and inpatient units at both UCSF and Zuckerberg San Francisco General Hospital are continually full or over crowded. Community hospitals near the CBOCs cannot perform the procedures that SFVAMC does.
Delays for emergency room and inpatient care for all those living in the Bay Area would increase.
Closure Impact on the VHA Budget
Last year, there were 5235 SFVAMC inpatient admissions. If SFVAMC inpatient units were to close, virtually every one of those patients would obtain non-VA care under new rules that automatically grant vouchers to the CCN for veterans who have to travel more than 30/60 minutes to the nearest VHA facility.
Multiple analyses of the financial impact of initiatives that expand VHA care for veterans in the private sector predict higher program costs. That stems from two factors: (1) more veterans would begin to use CCN, as it is financially more advantageous to have VHA pay for care than use other insurance, (2) procedures are more costly in the fee for service private sector, which has a built-in incentive to overtreat. One example is end of life care for veterans whose illnesses will be terminal. SFVAMC utilizes more palliative and hospice care than does the private sector, which is more likely to use aggressive, expensive treatments. (As an important added benefit, this kind of care makes it possible for patients to manage their chronic illness and die with comfort and dignity.)
Further, the difficulty of coordinating care in the non-VA sector also leads to higher costs and poorer outcomes.
Increasing use of inpatient care at non-VA facilities is more expensive than delivering care within SFVAMC.
Closure Impact on Readiness for Emergencies
The Fourth Mission of the VA is to support national, state, and local emergency management, public health, safety and homeland security efforts for veterans and non-veterans in the event of war, terrorism, national emergencies, and natural disasters. SFVAMC is a federal emergency response site.
In the event of an earthquake, wildfire or another emergency, there will be fewer triage ER and inpatient beds. It will also be more difficult to set up the kind of command center that the SFVAMC routinely organizes to track and assist veterans who are affected by such emergencies.
Closure Impact on Local Economy
The SFVAMC has approximately 2700 employees who generate millions of dollars for the local economy. Should the SFVAMC inpatient services be closed, the majority of these employees would be laid off. For many of them, especially those in support roles, finding gainful employment will be difficult. Veterans on compensated work therapy would face insurmountable challenges. Any decision about closing the SFVAMC must consider how job losses impact the local economy.
Russell Lemle, PhD, Senior Policy Analyst
Suzanne Gordon, Senior Policy Analyst