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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