Origin of the EM Program
The History of VHA Diagnostic Electron Microscopy
Diagnostic electron microscopy originated as one of the VA's approximately twenty-three designated Special Medical Services which also included such modalities as renal dialysis, renal transplant and cardio-pulmonary by-pass surgery. These Services were supported by specific appropriations and were present only in selected hospitals. The former office of the Assistant Chief Medical Director for Professional Services had the responsibility for the nurture, planning, site selection, management and evaluation of all the Special Services, and this duty was delegated to the appropriate professional service. For example, diagnostic electron microscopy was delegated to the Pathology Service in the VA's Central Office. Inherent in the establishment of electron microscopy units is the concept that teaching and research are legitimate and important activities. In the hospitals, the diagnostic EM units are organizationally part of the Pathology and Laboratory Medicine Services. In some instances, the Chief of the Laboratory Service may also be the director of the local EM program, but more frequently the responsibility is assigned to another pathologist with particular interest and skill in this field. Monitoring of Electron Microscopy units occurs by periodic evaluation of workload productivity and annual quality assurance assessment by a national committee of VA and non-VA pathologists.
FUNDING - background (under Specialized Medical Services Program) The EM programs received their basic funding from the appropriation that supported the Special Medical Services. The support for each approved program was specifically identified and provided for both the initial and the recurring costs. Initial costs include such items as the purchase of the EM and other necessary equipment and the construction or remodeling of space to accommodate the unit. Recurring costs consist of the salaries for the staff, the supplies and the service contract for maintenance of the EM. The indirect costs were supported from the general operating budget of the Medical Center. The selection of the electron microscope and other equipment is made locally, although the decision may be reviewed and approved in National Headquarters. In general, only high resolution transmission electron microscopes are acquired, but a few instruments that may be used also for scanning have been purchased. The salary allocation was sufficient to support on a full-time basis one pathologist and two technologists. This level of staffing is considered satisfactory for a diagnostic EM unit examining at least 250 specimens annually. Replacement of existing equipment, acquisition of new capital equipment and salaries for additional personnel including secretarial support must be provided by the hospital through regular budgetary procedures. Funding support consisted of 1.0 FTE physician calculated at Chief Grade, Step 3; 2 technologists calculated at GS 7/5; appropriate annual budget for supplies and service contract; electron microscope and related equipment, averaging $150,000; and necessary installation costs (renovation or construction). Starting in FY 1987, specialized medical care funding was no longer provided from Central Office sources. Individual Medical Centers provide the required funding to operate the EM program at that Medical Center. However, those EM funds previously targeted were included in the recurring funding base allocated annually to each EM program medical center but were not specifically targeted or identified for EM activities.
Another topic that requires brief description is the VA's extensive affiliations with medical schools (there are also affiliations with schools for dentistry and many allied health professions and occupations). There are now affiliate relations with more than 152 medical and dental schools. More than half of the U.S. practicing physicians have trained in VA facilities. Most of the pathology residency training in VA hospitals is conducted through integrated programs with the affiliated medical schools. The diagnostic EM units are all located in hospitals which are affiliated and provide pathology graduate medical education. The VA has statutory authority to enter into agreements with affiliated medical schools and other hospitals to share specialized and scarce patient-care services. These agreements are established most frequently for the sharing of the Special Medical Services. Sharing agreements for diagnostic electron microscopy are discussed later in more detail. An important component of those sharing agreements is that billing must be computed to recover actual cost of providing those services.
There are also in certain VA hospitals EM facilities that are part of the research and not the pathology program, The research facilities are funded separately from the diagnostic units and their selection and evaluation is handled through different channels. A limited number of diagnostic EM studies are carried out on research equipment in some hospitals that do not have diagnostic units, but information about such examinations is not collected by the Pathology & Laboratory Medicine Service in National Headquarters. In addition, some specimens are referred elsewhere, frequently to an affiliated medical school, from VA hospitals lacking EM resources.
