1
OVERVIEW OF THE STUDY

PURPOSE AND SCOPE

To accomplish its principal mission-related responsibilities of patient care, education, and research, how many physicians does the VA require?

The purpose of this study has been to develop a methodology to assist the Department of Veterans Affairs (VA) in answering this basic, but extraordinarily complex, question.

Specifically, the VA asked the Institute of Medicine (IOM) to develop ''a sound methodology for estimating the number of physicians, by specialty groupings, required for the efficient delivery of high-quality physician services'' (Institute of Medicine, 1987) in all programs and facilities operated by the Veterans Health Administration (VHA), which has responsibility for all VA physician-related activities.1

The VHA, headed by the chief medical director, operates the largest federal medical care delivery system in the United States, with about 1.1 million inpatient admissions and 22 million outpatient visits in Fiscal Year (FY) 1990. About 97 percent of its $11.6 billion budget in FY 1990 was devoted to medical care (U.S. Department of Veterans Affairs, 1991), and the great majority of medical care expenditures are for programs and services directly involving physicians; the scope of this study extends across these physician-related activities.

1  

 Specifically, the mission of VHA is to provide the following:

• Complete health care delivery service for the ambulatory and hospital care of eligible veterans;

• Program of education and training of health care personnel;

• Program of medical research; and

• Health care services to members of the Armed Forces during a war or national emergency.



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Physician Staffing for the VA: Volume I 1 OVERVIEW OF THE STUDY PURPOSE AND SCOPE To accomplish its principal mission-related responsibilities of patient care, education, and research, how many physicians does the VA require? The purpose of this study has been to develop a methodology to assist the Department of Veterans Affairs (VA) in answering this basic, but extraordinarily complex, question. Specifically, the VA asked the Institute of Medicine (IOM) to develop ''a sound methodology for estimating the number of physicians, by specialty groupings, required for the efficient delivery of high-quality physician services'' (Institute of Medicine, 1987) in all programs and facilities operated by the Veterans Health Administration (VHA), which has responsibility for all VA physician-related activities.1 The VHA, headed by the chief medical director, operates the largest federal medical care delivery system in the United States, with about 1.1 million inpatient admissions and 22 million outpatient visits in Fiscal Year (FY) 1990. About 97 percent of its $11.6 billion budget in FY 1990 was devoted to medical care (U.S. Department of Veterans Affairs, 1991), and the great majority of medical care expenditures are for programs and services directly involving physicians; the scope of this study extends across these physician-related activities. 1    Specifically, the mission of VHA is to provide the following: • Complete health care delivery service for the ambulatory and hospital care of eligible veterans; • Program of education and training of health care personnel; • Program of medical research; and • Health care services to members of the Armed Forces during a war or national emergency.

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Physician Staffing for the VA: Volume I In the statement of work agreed to by the VA and the IOM (Institute of Medicine, 1987), the designated primary study objective was the development of a "mathematical/statistical methodology, incorporating both empirically-derived and expert-judgment-based values in the methodology's algorithms, which translates quantitative measures of ... mission-related workload demands . . . into numerical estimates of physician staffing requirements." Data for these analyses would be derived from three sources: The VA's own information systems, yielding empirical observations on physician-patient workload relationships across the system (and thus reflecting what may be characterized as "internal" performance norms); "External" (to the VA) physician performance norms, as obtained directly or else inferred from other health care organizations in the public and private sectors; and Expert panels, which would evaluate the statistical models, the data used in them, and external staffing norms—and, in light of these assessments, recommend modifications to either the models or the staffing recommendations derived from them. The committee interpreted as its charge the development of a methodology capable of assessing: The number of physicians required to meet the current patient-care workload at VA medical centers (VAMCs). These assessments would be conditional on the scope and case acuity of patient workload; the number and type of residents; the availability of nonphysician personnel, such as nurses, allied health professionals, and other support staff; and other productivity-influencing factors, such as the presence of certain capital equipment. Future VA physician requirements, taking into account possible changes in the volume, mix, and case acuity of patient workload resulting from the aging of the veteran population. Likewise, the methodology should be flexible enough to incorporate projected changes in other factors influencing VAMC utilization, such as the distribution of veterans across eligibility-for-care categories and the proportion of females in the eligible population. The net effect on VA physician requirements if there were changes in the number, type, and intensity of VA-medical school affiliation relationships. In addition, there should be analyses of the potential effects of such changes on the VA's ability to accomplish the physician education component of its mission now and in future years. Over the years, the VA has published staffing guidelines for most health care provider categories, except physicians. This underscores the genuine complexities—clinical, economic, statistical, administrative, and political—that

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Physician Staffing for the VA: Volume I abound in attempting to estimate the number of physicians required to meet the VA's mission. In the majority of VAMCs, mission-related responsibilities are threefold: patient care, education, and research. In most of these activities, the VA staff physician does not function alone, but rather as a critical member of a team that may include residents, non-VA consulting physicians, nurses, nonphysician practitioners (e.g., physician assistants), and a variety of support staff. Hence, the number of physicians required in any specific VA setting will be a function of the availability and productivity of these other providers, who may function as either substitutes for or complements to the staff physician. Nonpersonnel factors (e.g., capital, floor space, the VAMC's proximity to the nearest medical school) may also be important determinants of physician productivity. The amounts of time to be allocated to research, classroom instruction of residents and others, continuing education, administration, and professional development all should figure directly into the computation of VA physician requirements. The approaches to VA physician staffing set forth in this report do attempt to account for the influence of these factors (subject to data limitations). Overall, however, the committee would characterize its product as a "first-generation methodology" (consistent, in fact, with language in the statement of work describing the anticipated outcome of the study). At the moment, the proposed methodology is capable of yielding defensible estimates of VA physician requirements, in the committee's judgment. But whether this methodology would lead over time to significant improvements in the efficiency and quality of VA health care can be determined only after it is implemented, then rigorously evaluated. ORGANIZATION AND CONDUCT OF THE STUDY Studies undertaken by the IOM (and the National Academy of Sciences, in general) are conducted by expert committees. These committees consist of individuals selected for their expertise on one or more topics germane to the study; collectively, all disciplines, research areas, and social perspectives important to a study are to be represented on the committee conducting it. The IOM committee conducting this study was organized in the spring of 1988; after all appointments had been made, it consisted of 19 members, including experts in the physician specialties relevant to the VA, nursing, allied health manpower, statistics, economics, operations research, and health services research. The committee had a broad representation by age, gender, and geographic location. Most members had, at some point, provided either patient care, clinical instruction, or research expertise at VAMCs. But, by design, no

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Physician Staffing for the VA: Volume I committee member was on the clinical or research staff of a VAMC during the period of the study. The committee roster appears in the front of this report. The study was developed partly on the basis of an analytical plan formulated by an earlier IOM committee, which had been appointed in response to a request from the VA. This earlier study, completed in 1985, laid the broad intellectual groundwork for the current effort (Institute of Medicine, 1985). In its conduct of the study, the committee was advised by 11 panels: data and methodology (working on all components of the study, but focusing especially on statistical analyses), affiliations (examining VAMC-medical school affiliation relationships), nonphysician practitioners (focusing on a selected set of providers, including physician assistants and nurse practitioners), and six specialty and two clinical program panels (each concerned with physician requirements from the perspective of its own designated discipline or program). The six specialty panels were medicine, which encompassed all medical subspecialties; surgery, which encompassed all surgical subspecialties, plus anesthesiology; psychiatry; neurology; rehabilitation medicine, whose purview also included spinal cord injury; and other physician specialties, defined by the committee to include the specialties of laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology. The two clinical program panels, both multidisciplinary in composition, were ambulatory care and long-term care. Of the 11 panels, eight were defined at the study's inception; the neurology, ambulatory care, and nonphysician practitioners panels were instituted by the committee during the course of the study. Each panel consisted of a mix of VA-staff and non-VA members, with the former never constituting a voting majority. Each panel chair was also a member of the committee. Throughout the study, the committee also was advised by a VA liaison committee, appointed by the VA chief medical director. It consisted of 22 VA staff members, including experts in the clinical specialties, administration, and health services research; the VA's project officer for the study was an ex officio member of this committee. The liaison committee's recommendations were, by design, nonbinding, and the study committee welcomed and benefited considerably from this group's thoughtful counsel. The rosters for all 11 panels and the VA liaison committee are found in Appendix A of this report. The complex nature of the topic, coupled with the charge that the committee produce a well-researched product suitable for policy application in the VA, led to there being an unusually large number of committee and panel meetings. From June 1988 through December 1990, the study committee met eight times and its panels met as follows: data and methodology, 11; affiliations, 5; nonphysician practitioners, 3; and the eight specialty and clinical program panels, twice each for a total of 16. Over this period, the VA liaison committee

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Physician Staffing for the VA: Volume I met with either the study committee or its staff on four occasions. In sum, there were 47 meetings, each of 1 to 2 days' duration. From November 1989 through December 1990—an intensely active period during which all components of the methodology were being brought to fruition and tested—a total of 32 committee and panel meetings were conducted. THE COMMITTEE PERSPECTIVE After considerable analysis and much deliberation through many meetings, the committee recommends a new methodology for determining VA physician requirements. It calls for estimates of physician requirements to be derived simultaneously through competing analytical approaches, principally involving statistical modeling and expert judgment processes. These alternative estimates form the boundaries within which specific physician staffing targets are derived through an open process of evaluation and discussion, termed the Reconciliation Strategy. The methodology is multifaceted because no one approach to determining physician requirements is without its flaws. But when the approaches are considered in concert, the opportunity is created to bring the full range of relevant information to bear on the problem. The committee's principal charge was to produce a methodology, not implement it. Consequently, this report does not contain specific estimates of how many physicians the VA requires systemwide (though it reports physician requirements in detail for a small set of VAMCs analyzed experimentally during the study). What the report does contain are precise recommendations for how the methodology, after further empirical refinements, could be used to determine physician staffing, by specialty, at any facility in the VA system. Moreover, physician requirements can be calculated for any desired grouping of facilities by directly aggregating the corresponding facility-specific estimates. A useful by-product of the methodology is that at any point in time, it is possible to compare the actual and model-predicted performance of individual VAMCs in terms of physician staffing intensity and workload productivity. As the study proceeded, it became clear to the committee that this resource allocation problem should be attacked in an "evolutionary" fashion, with the methodology presented here as the vehicle to launch the evolution. In its current form, the methodology provides a better framework than exists presently for determining VA physician requirements, in the committee's view. On the basis of the many experimental analyses reported in this study, the committee concludes that the methodology is capable, at the moment, of yielding defensible staffing recommendations. But it can, and should, be improved over time. In the course of this report, the committee presents a number of proposals for testing and refining the methodology. No meaningful testing and refining is possible, however, unless the staffing models are first put to use. In

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Physician Staffing for the VA: Volume I subsequent chapters, the committee recommends, in quite specific terms, the analyses that should be performed, and why. If the VA adopts, and adapts as needed, the proposed methodology, the quality of its physician staffing decisions should improve over time—and so should the quality of VA health care. REFERENCES Institute of Medicine. 1985. Plan for a Study to Develop Methods Useful to the Veterans Administration in Estimating Its Physician Needs . Washington, D.C. Unpublished. Institute of Medicine. 1987. Study Workplan (Statement of Work) for a Study to Develop Methods Useful to the Veterans Administration in Estimating Its Physician Needs. Washington, D.C. Unpublished. U.S. Department of Veterans Affairs. 1991. FY 1992 Budget Submission. Unpublished.