2
BACKGROUND

This chapter briefly addresses two categories of issues that bear on the committee's understanding and conduct of the study.

First, as a prelude to investigating how many physicians the VA should have, the number that it does have is examined by specialty and allocation across the major mission-related activities of patient care, education, and research. The data are for Fiscal Year (FY) 1989, the year used for most of the empirical analyses in the study. In addition, factors thought to influence the number of physicians in a given specialty at a given VA medical center (VAMC) at any point in time are discussed. It is into this VAMC decision-making environment that the committee's proposed physician requirements methodology would be introduced.

Second, among the working assumptions invoked by the committee in the conduct of the study, several undergirding ones should be noted at the outset and therefore are discussed below.

CURRENT ALLOCATION OF PHYSICIANS IN THE VA

Total Physicians, By Specialty

For each of 11 specialty categories, data on the total quantity of VA staff physicians nationwide for FY 1989 are summarized in Table 2.1. For each specialty, the absolute and the percentage allocation of physicians to direct patient care (and miscellaneous other activities), education, and research are shown. The three dominant physician specialties, in size, are medicine, psychiatry, and surgery; in every specialty, the great majority of manpower is devoted to patient care (miscellaneous activities account for less than 5 percent of the total).



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Physician Staffing for the VA: Volume I 2 BACKGROUND This chapter briefly addresses two categories of issues that bear on the committee's understanding and conduct of the study. First, as a prelude to investigating how many physicians the VA should have, the number that it does have is examined by specialty and allocation across the major mission-related activities of patient care, education, and research. The data are for Fiscal Year (FY) 1989, the year used for most of the empirical analyses in the study. In addition, factors thought to influence the number of physicians in a given specialty at a given VA medical center (VAMC) at any point in time are discussed. It is into this VAMC decision-making environment that the committee's proposed physician requirements methodology would be introduced. Second, among the working assumptions invoked by the committee in the conduct of the study, several undergirding ones should be noted at the outset and therefore are discussed below. CURRENT ALLOCATION OF PHYSICIANS IN THE VA Total Physicians, By Specialty For each of 11 specialty categories, data on the total quantity of VA staff physicians nationwide for FY 1989 are summarized in Table 2.1. For each specialty, the absolute and the percentage allocation of physicians to direct patient care (and miscellaneous other activities), education, and research are shown. The three dominant physician specialties, in size, are medicine, psychiatry, and surgery; in every specialty, the great majority of manpower is devoted to patient care (miscellaneous activities account for less than 5 percent of the total).

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Physician Staffing for the VA: Volume I Included in the table are all physicians on the VA payroll who are based in one (or more) of the system's 172 medical centers, 63 independent or satellite outpatient facilities, or 122 nursing homes. Excluded from the table are VA physicians in administrative positions not based at one of these sites (e.g., a position in VA Central Office in Washington, D.C.) and non-VA physicians who periodically perform consultations at VAMCs either for a set fee or free of charge. As discussed in chapters 4 and 9, there are no nationwide data measuring either the quantity or the clinical contributions of these non-VA physicians. Although data on VA physicians in central administration are available, the proposed methodology will not deal with this arena of activity, as discussed momentarily. (Also excluded from Table 2.1 are physicians at the VAMC who are not assigned formally to one of the 11 specialty categories in the VA's personnel accounting system, e.g., physicians assigned, instead, to the spinal cord injury or ambulatory care cost centers.) All VA personnel, including physicians, are measured in terms of Full-Time-Equivalent Employees (FTEE). In general, one FTEE translates into a 40-hour-per-week commitment; for example, someone working 20 hours per week would represent 0.5 FTEE, whereas five people who each work 12 hours per week contribute a total of 1.5 FTEE. For staff physicians, the meaning of FTEE is somewhat more complicated than this in practice. The VA payroll system essentially divides the 40-hour week into eight parts, so that a full-time physician is termed an "8/8ths" employee, a half-time physician is a "4/8ths" employee, and so on. For physicians who are not full time, the "eighths" assignment is supposed to be an accurate statement of the average hourly commitment per week. A physician classified as "5/8ths" is assumed to spend about 25 hours per week at the VAMC. On the other hand, it is well understood that a full-time physician's time commitment is not strictly limited to 40 hours per week; it may exceed this, on occasion or frequently, as required to meet the VAMC's missions of patient care, education, and research. There are no available data on the average hours per week worked by full-time VA physicians, and hence no way presently to derive an "adjusted" FTEE count that accurately reflects the total number of hours worked. This caveat must be kept firmly in mind when interpreting physician staffing data throughout the report. How Physician FTEE Levels Currently Are Determined At present, the VA has no national, centrally directed policy for determining how many physicians it needs. The number of physician FTEE, by specialty, at each VA medical site in FY 1989 (as reflected, ultimately, in Table 2.1) emerged from a decision process that is local in nature and influenced by

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Physician Staffing for the VA: Volume I historical staffing patterns, perceived workload burdens, opportunities for productivity enhancement, national program initiatives, and local market forces. Each fiscal year, a VAMC is assigned a total operating budget and a ceiling on total personnel—but no specific directives or guidelines on how many physician FTEE, overall or by specialty, it should have. The latter decision is at the facility's discretion. The committee could find no formal documentation describing how physician FTEE are assigned, but it has concluded from various commentaries during the study that the following factors are important: Historical Considerations. Within a given specialty service at a VAMC in a given fiscal year, there will be a certain number of designated physician FTEE—a type of "historical base" that is the product of myriad previous staffing decisions by administrators at the facility. There are a number of practical limitations on the ability of that service chief to alter physician staffing significantly. With VA budgets growing slowly, at best, it is often the case that the chief can acquire additional physicians only if the VAMC is willing to reduce staffing, or other resource commitments elsewhere in the facility. Not surprising, few fellow service chiefs are willing to surrender their physician slots. Further, the ability of a chief of staff or facility director to downsize a service is hampered by the fact that all full-time VA physicians have what amounts to "tenure"; to attempt to remove or transfer these physicians over their objections can be an arduous and costly endeavor. The result, in sum, is that each year's physician FTEE total is likely to be similar to the previous year's. Perception That Workload Is Changing. When there is a perception, empirically based or not, that a given specialty will be unable to meet patient workload demands, that specialty is sometimes able to argue successfully for additional physician FTEE. A Reward for Good Performance. When a specialty at the VAMC can demonstrate that it has used existing physician FTEE efficiently, it may bid successfully for additional physicians to expand its scope of operation. Pursuing New Programs. Periodically, VA Central Office will invite facilities to compete for funds supporting the development of new, targeted programs, for example, Geriatric Research, Education and Clinical Centers, and Post-Traumatic Stress Disorder initiatives. In most cases, successful applicants will receive funding for a designated additional number of physician FTEE to carry out the initiative. These new physicians are "add-ons," requiring no reduction in existing physician FTEE levels. Marketplace Considerations. In some cases, a given specialty will have clearance from its VAMC to hire additional physicians but simply cannot attract them, given the facility's geographic location in combination with existing VA salary levels. This problem of "absolute" shortages appears to arise more

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Physician Staffing for the VA: Volume I frequently in VAMCs lacking academic affiliations, particularly in rural areas and particularly for highly specialized physicians. In other cases, a VAMC may find that it can acquire the additional physicians it requires—but only at salaries well beyond those established by the VA. When this occurs, there are several options. The VAMC may negotiate a contract to obtain targeted amounts of physician FTEE in certain specialties (perhaps from a group practice or medical center). If the VAMC is affiliated with a medical school, it may attempt to acquire assistance from "consulting & attending" or "without-compensation" physicians—and, in the process operate at well below market rates. Finally, a VAMC may respond by hiring nonphysician practitioners. For example, a VAMC unable to find, or afford, an additional psychiatrist may acquire some combination of psychologist and social worker FTEE to handle a portion of the psychiatry workload. SOME UNDERGIRDING ASSUMPTIONS There are at least four topics that should be discussed in advance of the methodology's presentation. The Methodology Focuses on Physician FTEE for VAMCs The proposed methodology is intended to help the VA determine the quantity of physicians, measured in FTEE, required to meet the mission-related demands of the VAMC. Two important points must be addressed. First, the committee recognizes that staff physicians serving in administrative positions in VA Central Office and other sites external to the VAMC have contributed significantly to the VA's mission-related activities of patient care, education, and research. However, the committee regards the determination of FTEE for this purpose as traditionally a matter of administrative discretion and, in any event, beyond its technical competence. Second, the Institute of Medicine was not asked to analyze the associated budgetary cost of alternative physician staffing levels. Nor was it asked to consider the practical difficulties that might arise in implementing staffing recommendations, given current VA salary ceilings and variations in the geographic concentration of physicians. The committee did take note of the following administrative point advocated by some members of the specialty and clinical program panels. In certain specialties (e.g., anesthesiology), the VA physician salary ceiling is sufficiently below the market rate of compensation that a facility may have difficulty acquiring the quantity of FTEE authorized in its budget. These panel members contended that, in such cases, a VAMC therefore should be assigned more

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Physician Staffing for the VA: Volume I physician FTEE than formally recommended in the methodology in order to compensate for the adverse effect of VA salary ceilings.1 In reality, this problem is apparently overcome in some cases by compensating the part-time VA physician from a combination of VA and non-VA sources, a tactic facilitated if the VAMC has an affiliation agreement with a neighboring medical school. It is also ameliorated by the use of non-VA consulting physicians who, through these affiliation agreements, render care at the facility at nominal rates or without compensation. The committee believes that such issues are important and must be squarely addressed by the VA. However, the methodology has been focused steadfastly on one primary issue: the physician FTEE required, in fact, to meet the VA's patient care, education, and research commitments in the field. Nonetheless, the committee does consider (in chapter 7) the advisability of tying the methodology to the VA budgetary process. Because this step would serve to enhance the effectiveness and validity of the methodology itself, the committee recommends that this linkage be achieved. This Is Not a Needs-Based Approach As noted in chapter 1, the VA requested a methodology for deriving physician requirements to meet current and future ''workload demands,'' that is, current and future veteran utilization of the system. Not addressed in this study, by the VA's own design, is the issue of physician staffing required for the amounts and kinds of health care that veterans may "need," however that term is defined. (Need may be defined biologically or clinically, or in terms of the access to care required for equity or social justice.) Thus, the scope of this analysis, and the approaches taken, differ in some significant ways from those adopted by the Graduate Medical Education National Advisory Committee (GMENAC) (Department of Health and Human Services, 1981), and the Council on Graduate Medical Education (COGME) (Buerhaus and 1    For example, suppose the salary ceiling in specialty s is $80,000 (per FREE) and the market rate is $100,000. The facility would simply not be able to hire one full-time physician in s, unless the advantages of working in the VA (e.g., possibly reduced hours, professional stimulation, public service) were sufficient to compensate for the $20,000 salary differential. To acquire one FTEE in s through the addition of part-time physicians (working various "8ths"), a similar situation arises. The facility would need to have 1.25 budgeted slots in s to afford the manpower equivalent of one FTEE—unless the nonpecuniary aspects of VA service were attractive enough to induce specialists to sign up at below-market rates. These panel members knew, of course, that current VA personnel policies could not formally accommodate such a proposal. Their contention, simply, was that the total package of VA inducements is often not adequate to allow the facility to hire the staff physician FTEE for which it has nominally budgeted.

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Physician Staffing for the VA: Volume I Zuidema, 1990). In both the GMENAC and COGME studies, the focus was (and is) on developing a "needs-adjusted" estimate of physician requirements. However, the methodology presented in chapters 4 through 7 could readily be adapted to accommodate a needs-based approach if the VA were subsequently to develop an operational definition of "need" along with guidelines for translating needs into expected patient workload. This is because those parts of the methodology for determining physician requirements to handle a given workload operate quite distinctly from the part (presented in chapter 8) for estimating what the workload will be. A variety of alternative demand-based and needs-based workload estimation approaches could be incorporated into the overall methodology at a later date. In particular, a needs-based approach that emphasizes both primary care and prevention could be well accommodated. Assuring the Quality of Care In developing a physician requirements methodology, perhaps the biggest challenge facing the committee was determining how to derive physician FTEE in a way that promotes high-quality medical care. The problems here are numerous and substantial. There is little consensus, either within or outside the VA, on how "quality" should be defined and measured. For any selected quality indicator (e.g., mortality), there is considerable uncertainty about the effects of particular medical interventions. There are virtually no studies in the clinical literature linking outcome-oriented quality measures to the intensity of physician staffing. In response, the committee's physician requirements methodology has the following features: Clinical judgment plays a critical quality assurance role. The expert judgment-based approach to physician staffing presented in chapter 5 complements—and frequently serves as a counterpoint to—staffing approaches based on the statistical analysis of existing VA data relating current physician staffing to current workload production. Physician requirements derived from these statistical models (see chapter 4) do reflect, in sum, the nature and the quality of current clinical decision making in the VA. During this study, the committee frequently heard from members of its specialty and clinical program panels that quality is sometimes compromised in the VA because of resource inadequacies. Hence, the argument goes, to base staffing decisions on statistical models estimated from current data will not promote quality care. Although the committee conducted no formal analyses to confirm or refute these statements, it is vitally concerned that physician FTEE levels derived from the methodology be consistent with high-quality care.

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Physician Staffing for the VA: Volume I In response, the committee has established an overall framework for the methodology—termed the Reconciliation Strategy (see chapter 6)—that allows for a balanced use of statistically based and expert judgment models in the calculation of physician requirements. In addition, the committee has demonstrated that if the VA can develop models linking quality indicators to physician staffing levels, physician FTEE can be derived from the statistical models in ways that meet designated quality standards (see chapter 7). In this regard, the committee applauds work recently begun by the VA Office of Quality Management to develop such indicators and explore their relationship to measures of resource intensity. Finally, the committee's proposed strategy for implementing the methodology emphasizes the importance of analyzing, prospectively and rigorously, the effects of physician staffing levels on outcome measures of quality. These results would be incorporated directly into the methodology's component models so that subsequent physician staffing recommendations are consistent with quality-of-care criteria. The Methodology Must Be Relevant to the Present, Flexible for the Future In the physician requirements methodology proposed here, it is assumed that health resource allocation in the VA of the future will be centrally directed and locally executed. However, the committee advocates a strong, two-way dialogue between VA Central Office and the individual VAMCs as essential to improving both the local acceptability and the empirical validity of the methodology over time (see chapter 7). In its analyses, the committee has assumed that, for the foreseeable future, the VA will continue to provide health care directly to veterans, on a large scale, through a network of its own hospitals, clinics, and nursing homes. Hence, the committee did not investigate how physician requirements might be determined under radically different scenarios, for example, that veterans might simply be issued vouchers for the purchase of medical insurance or health care from any provider. The committee strongly suspects that the methodology presented in chapters 4 through 8 could be suitably modified to accommodate such new scenarios. The most substantial modifications would likely be required in the workload projection models (chapter 8) rather than in the core pieces of the methodology (chapters 4 through 7). Such speculative issues will not be pursued further in this report. In developing and testing the methodology, the committee did not specifically analyze the additional requirements for VA physicians in the event of a war or other national emergency. This issue is relevant in that the VA must provide medical contingency backup to the Department of Defense under such

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Physician Staffing for the VA: Volume I emergency conditions (see note 1 in chapter 1). In fact, during the recent Persian Gulf War, the VA established specific contingency plans for treating the expected military casualties. There are two basic difficulties in examining this staffing question empirically. First, the case mix and severity of military casualties, characterized by a high incidence of acute trauma cases, would likely differ significantly from that of the current VA population. The statistically based and expert judgment staffing models developed in this study are both empirically grounded in the current practice of medicine in the VA. The extent to which the resulting workload-to-physician relationships apply to a wartime caseload requires careful investigation; adjustments to the models would likely be required. Second, the models for estimating future patient workload (see chapter 8) are based similarly on recent VA patient utilization experience and simply do not address the issue of emergency demands on the system. Nonetheless, the committee believes that a methodology, similar in principle to the one proposed here, could be applied successfully to determine physician staffing for a wartime caseload. However, a considerable amount of additional empirical analyses would be required to achieve the necessary empirical adjustments. One assumption the committee did not make was that the VA health care system of the future would necessarily exhibit the same configuration of inpatient, ambulatory, and long-term care programs and services as presently seen. For the non-VA sector, there have been relatively dramatic shifts in recent years from inpatient to alternative forms of care, especially ambulatory and long-term care. The committee notes that similar pressures exist in the VA. This increased emphasis on primary care for the eligible veteran could indeed imply a very different deployment of manpower than seen in the present VA system, with its generally strong orientation toward hospital-based tertiary care. This is a major reason the methodology emphasizes that physician workload relationships be analyzed at what will be termed the "patient care area" (PCA) level, as well as at the facility level. A PCA is an administratively defined locus-of-care site whose patients share certain clinical characteristics; PCAs include, for example, the inpatient medicine bed section, the nursing home, and the psychiatric clinics within the ambulatory care program. The committee's underlying precept is that PCAs are useful not only in the analysis of current physician requirements, but can serve as the building blocks for models to determine physician requirements for types of VAMCs not presently seen in the system. For example, to estimate FTEE requirements for a VAMC of the future offering primarily psychiatric, intermediate, ambulatory, and nursing home care, the analyses would focus on the physicians required for these four categories of PCAs. Currently, there may be few, or no, VAMCs configured just this way. But the physician requirements methodology can still yield FTEE estimates for

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Physician Staffing for the VA: Volume I such a facility—through either a statistically based approach, an expert judgment approach, or some amalgam of the two. The committee feels that it is crucial that the methodology possess this degree of flexibility. With the size and age structure of the veteran population changing significantly, the VA health care system of the future may look quite different than the present one. In designing a physician requirements methodology, however, it was not the committee's intent either to defend and preserve the status quo or to overturn it in favor of a newly configured VA system. Rather, the methodology should be seen as a vehicle for calculating physician requirements for whatever programs and services the VA determines to be appropriate. That is, the methodology is not a substitute for fundamental policy choice—it is a means for helping implement those choices once management has determined the needs of the system. REFERENCES Buerhaus, P.I., and G.D. Zuidema. 1990. On the supply of physicians. Archives of Surgery 125:1425-1429. U.S. Department of Health and Human Services. 1981. Summary Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health aim Human Services. Vol. I. GMENAC Summary Report. DHHS Publication No. (HRA) 81-651. Washington, D.C.: Government Printing Office.

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Physician Staffing for the VA: Volume I TABLE 2.1 Total Staff Physicians by Selected Specialties at VAMCs, in FY 1989, with FTEE Allocated Across Major Activity Categories   Physician FTEE1       Physician Specialties Direct Care & Miscellaneous Activities Education2 Research Total Medicine 2,360.1 482.6 451.5 3,294.2   (71.6) (14.6) (13.7)   Surgery 985.0 265.7 127.4 1,378.1   (71.5) (19.3) (9.2)   Psychiatry 1,240.3 189.0 130.0 1,599.3   (79.5) (12.1) (8.3)   Neurology 197.0 42.1 44.8 283.9   (69.4) (14.8) (15.8)   Rehabilitation Medicine 238.6 23.8 7.9 270.3   (88.3) (8.8) (2.9)   Spinal Cord Injury 94.1 3.3 3.6 101.0   (93.2) (3.3) (3.6)   Anesthesiology 204.1 39.6 12.8 256.5   (79.6) (15.4) (5.0)   Laboratory Medicine 436.4 39.5 34.6 510.5   (85.5) (7.7) (6.8)   Diagnostic Radiology 475.4 44.7 21.3 541.4   (87.8) (8.3) (3.9)   Nuclear Medicine 114.7 15.6 14.2 144.5   (79.4) (10.8) (9.8)   Radiation Oncology 33.4 4.4 1.5 39.3   (85.0) (11.2) (3.8)   1 Percentage of total FTEE for the specialty is shown in parentheses. 2 Includes FTEE allocated to the training of residents and other staff, to the administration of education programs, and to continuing education for the VA physician. SOURCE: VA internal accounting data, with subsequent analyses performed by the VA's Boston Development Center, Braintree, Massachusetts.