6
CHOOSING AMONG ALTERNATIVE APPROACHES TO DETERMINING PHYSICIAN STAFFING

The central issue facing the VA decision maker is how to determine physician requirements—that is, which methodological approach(es) should be adopted.

Three general approaches have been introduced. The analyses in chapter 4 demonstrated how physician requirements can be derived from statistical models that incorporate existing VA data. Specifically, the committee has developed Empirically Based Physician Staffing Models (EBPSM) with two, complementary variants: the production function (PF) and the inverse production function (IPF). In chapter 5, two alternative expert judgment models for physician staffing were introduced—one based on the Detailed Staffing Exercise (DSE) and the other on the Staffing Algorithm Development Instrument (SADI). A third approach also discussed in that chapter would involve using non-VA physician staffing criteria, or external norms, for guiding the decision about physician requirements in the VA.

(A fourth approach is to adopt no new methodology. Rather, the VA decision maker would hold to the status quo; there would be no new guidelines or requirements for physician staffing. The committee rejects this option—and all others not based on operating principles that are clearly specified, logically correct, and appropriate for policy making by some reasonable criteria.)

STRATEGIES FOR RECONCILING THE APPROACHES

Over the final months of the study, the committee examined four alternative decision strategies for using these staffing approaches (singly or in combination) to derive the total physician FTEE, by specialty, required for a given E4 medical center (VAMC). For each specialty (e.g., medicine) or program area (e.g., ambulatory care) the strategies called, in turn, for the VA decision maker to:



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Physician Staffing for the VA: Volume I 6 CHOOSING AMONG ALTERNATIVE APPROACHES TO DETERMINING PHYSICIAN STAFFING The central issue facing the VA decision maker is how to determine physician requirements—that is, which methodological approach(es) should be adopted. Three general approaches have been introduced. The analyses in chapter 4 demonstrated how physician requirements can be derived from statistical models that incorporate existing VA data. Specifically, the committee has developed Empirically Based Physician Staffing Models (EBPSM) with two, complementary variants: the production function (PF) and the inverse production function (IPF). In chapter 5, two alternative expert judgment models for physician staffing were introduced—one based on the Detailed Staffing Exercise (DSE) and the other on the Staffing Algorithm Development Instrument (SADI). A third approach also discussed in that chapter would involve using non-VA physician staffing criteria, or external norms, for guiding the decision about physician requirements in the VA. (A fourth approach is to adopt no new methodology. Rather, the VA decision maker would hold to the status quo; there would be no new guidelines or requirements for physician staffing. The committee rejects this option—and all others not based on operating principles that are clearly specified, logically correct, and appropriate for policy making by some reasonable criteria.) STRATEGIES FOR RECONCILING THE APPROACHES Over the final months of the study, the committee examined four alternative decision strategies for using these staffing approaches (singly or in combination) to derive the total physician FTEE, by specialty, required for a given E4 medical center (VAMC). For each specialty (e.g., medicine) or program area (e.g., ambulatory care) the strategies called, in turn, for the VA decision maker to:

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Physician Staffing for the VA: Volume I Adopt one dominant approach. For example, the core of the methodology could be an empirically based model, but expert panels would be appointed to evaluate results. Or, the core of the methodology could be an expert judgment approach, for example, based on the SADI, but these judgments would be tempered by reference to external norms and the results from the EBPSM. Or, the core of the methodology could be external norms, as developed and revised by expert panels. Whether or not all specialties and program areas would be guided by the same dominant approach would be a separate decision. Use two or more approaches in conjunction to derive a range of physician staffing estimates. There would be no formal model or algorithm for either justifying or reconciling differences among the approaches, or any formal procedure (e.g., mathematical weighting scheme) for merging their FTEE recommendations. Instead, the VA decision maker would have a menu of physician staffing estimates, each defensibly derived. This strategy would serve to reject physician FTEE levels falling outside the boundaries established by the menu but would be effectively neutral about levels within the boundaries. Use two or more approaches in conjunction to derive a range of physician staffing estimates sensitive to assumptions about budgetary and other constraints. This strategy differs from the previous strategy (B) only in its advocacy of sensitivity analysis, optimization models, and related techniques to help the VA decision maker investigate important "what if" questions. For example, Suppose a VAMC wanted to have physician FTEE in 1995 at levels recommended by the SADI methodology. What would be the budgeted cost of this (in real terms)? Clearly, similar calculations could be performed for the DSE and both variants of the EBPSM. But suppose the VAMC could spend no more on physicians overall (in real terms) than it did in 1989. Suppose this amount is insufficient to pay for all of the SADI-recommended FTEE. How many staff physicians, in each specialty, should the VAMC seek to employ in 1995 if it wanted, for example, to (1) adhere to the interspecialty ratios implied by the SADI, or (2) equalize the percentage by which each specialty's FTEE level is below that recommended by the SADI? Suppose the VAMC wanted to minimize 1995 expenditures on physicians, subject to meeting important constraints: (1) staffing levels would be high enough (according to the PF model) to handle the projected workload and (2) the FTEE ratios between certain specialties and between staff physicians and residents would lie within prescribed bounds on each PCA. What is the resulting implied physician FTEE level in each specialty at the VAMC?

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Physician Staffing for the VA: Volume I Clearly, there are many such inquiries that relate physician staffing to budget. Through some integrative process (e.g., mathematical weighting scheme), combine physician staffing results from two or more approaches to produce either a single FTEE estimate or a range of estimates. In the committee's terminology, this combining either could be done ''holistically'' (Strategy D. 1) to produce, in a single weighted-average calculation, an overall FTEE total for each specialty or program area, or it could be implemented in a "disaggregated" format (Strategy D.2), which allows for different weights to be applied to the different component parts of physician FTEE; the total required FTEE in a specialty or a program area would be the sum of these weighted components. The sensitivity analyses described above could be conducted as well under either variant of this strategy. THE RECONCILIATION STRATEGY Committee's Recommended Approach As an overall framework for determining VA physician requirements (given workload and other factors), the committee endorses Strategy D.2, the "disaggregated weighted-average" variant of D. Henceforth, this is termed the Reconciliation Strategy. There are many possible formulations of this strategy, but the committee prefers the following one for reasons discussed shortly. (For the purpose of illustration, the medicine service is referenced and the reconciliation is assumed to focus largely on the following two approaches: the PF variant of the EBPSM and the SADI.) Physician FTEE where X1 = total internist FTEE (staff, contract, non-VA consultants), as derived from the PF and other facility-specific data, for direct care on medicine inpatient and outpatient PCAs; consultations on all other PCAs; resident training on PCAs and in classroom; administration by chief and others; and leaves of absence of all types; X2 = the same as X1, but derived from the SADI;

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Physician Staffing for the VA: Volume I Rl = internist research FTEE, as derived from an empirically based approach; R2 = the same as R1, but derived from the SADI; C1 = internist FTEE for continuing education, as derived from an empirically based approach; C2 = the same as C1, but derived from the SADI; and b, c, d = weighting parameters, each lying on the [0,1] interval. Two technical points should be noted: First, by varying the parameters b, c, and d jointly across their ranges (the unit interval in each case), corresponding ranges of physician FTEE estimates are generated. Second, in this specification of the strategy, physician FTEE is disaggregated into three components. By far, the most significant as a percentage of total FTEE is that denoted by X. It is the component for which there is the greatest amount of empirically based and expert judgment information. However, for completeness, it is important that all FTEE components be reflected in Equation 6.1. Although it is conceptually possible to disaggregate X further into patient care, resident education, administration, and leaves of absence subcomponents—and to break these out by PCA—the committee has not done so. Although both the SADI and the DSE can accommodate this detailed level of breakout, neither the IPF nor the PF can because of limitations in the VA's Cost Distribution Report (CDR) (see chapter 4). In particular, the IPF is structured precisely at the level of aggregation (i.e., at the facility level) reflected in the operational definition of X; this is not the case for the PF, but it is still not possible to separate out the administration and leaves-of-absence portion of FTEE in the PF. Specifying the Reconciliation Strategy as shown in Equation 6.1 allows all four of these FTEE estimation procedures (SADI, DSE, IPF, and PF) to be applied in a parallel fashion, so that their implications for well-defined pieces of total FTEE can be validly compared. Interpretation of the Strategy The committee emphasizes the following substantive points: 1. The formula for deriving FTEE in each of the three components of Equation 6.1 consists of two terms, which will be called, respectively, the Empirically Driven Baseline and the Modifier. Thus, for patient care, resident education, administration, and leaves of absence, the Empirically Driven Baseline is X1, and the Modifier is b(X2-X1).

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Physician Staffing for the VA: Volume I This configuration of the Reconciliation Strategy conveys a particular policy perspective. In determining physician requirements for each specialty or program area, the first step is to derive FTEE estimates from a variant of the EBPSM. This Baseline estimate could be obtained from either the IPF or the PF, but the important point is that it emerges from a model driven by data reflecting (subject to measurement error) the current reality of medical practice in the VA. But, the physician requirements analysis does not stop there. The second step is to investigate whether the Baseline FTEE estimate should be modified in light of factors threatening the validity of the EBPSM. As implied by discussions in chapters 3 and 5, these factors fall into one of two broad groups of data-related problems: (1) simple measurement and recording errors and (2) observations relating physician FTEE and workload that are "clinically inappropriate," because of current VA resource constraints and other factors. To the degree that the validity of the Baseline estimate is threatened, one applies the Modifier. At the extremes, the Modifier can dominate entirely or have no influence at all, as discussed shortly. This articulation of the Reconciliation Strategy reflects the committee's view that there are clear advantages, organizational and methodological, to building a physician requirements methodology around the EBPSM—if the important statistical and clinical assumptions are met. If they are not met, then modification of the empirically driven estimates, whether through expert judgment staffing assessments or the application of external norms, is in order. 2. Implementing this Reconciliation Strategy requires two types of policy choices from the VA decision maker. For each FTEE component (i.e., X, R, and C), which empirically based approach should be selected? Likewise, what expert judgment approach (SADI or DSE) should be used in calculating the Modifier? Given these, what are the most appropriate values for the weighting parameters b, c, and d? Once these parameters are set, the "compromise" between the Baseline and the Modifier is effectively accomplished. For example, if the VA decision maker determines that physician requirements should be derived entirely on an empirically driven basis, then b, c, and d would all be set to 0 in Equation 6.1. But if, after due consideration, it is determined that the Baseline estimate is entirely unacceptable, the Modifier would be adopted in full by setting b = c = d = 1. For each FTEE component, the Modifier would be constructed by choosing an appropriate expert judgment or external norm FTEE estimate, in turn, for X2, R2, and C2. Parameter values between the 0-1 endpoints would reflect the VA decision maker's view that "due weight" should be accorded to both the Empirically Driven Baseline and the Modifier. For example, if X1 = 14 and X2 = 18, a determination that equal weight be given to both approaches would imply that b = 0.5 and the recommended FTEE is 16 for this component of the total.

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Physician Staffing for the VA: Volume I 3. Hence, the Reconciliation Strategy offers considerable flexibility in determining physician requirements across specialties and program areas. For specialty A, the X component of FTEE might be computed as a weighted average of results from the PF model and the DSE. For specialty B, the "core" approaches to staffing reflected in the weighted average might be the IPF and the SADI. Even assuming the VA decision maker were to select the same core approaches for both specialties, the weighting parameters b, c, and d could vary between the two. It follows that the Reconciliation Strategy should not be viewed as a preset staffing formula, but as a framework for choosing FTEE requirements. The choice is a structured one, framed essentially by whatever core approaches to staffing the decision maker selects for computing the Baseline FTEE estimate and the Modifier. From rigorous analyses involving the PF, the IPF, or other empirical data come estimates of X1, R1, and C1. From rigorous analyses involving the SADI, DSE, or external norms come estimates of X2, R2, and C2. In sum, these analyses define the permissible FTEE range for each of the three components in Equation 6.1. Note that for any of the three FTEE components, this range may or may not include the status quo level of physician FTEE, as indicated in the VAMC's current CDR. That is, it is possible for the Empirically Driven Baseline FTEE recommendation to be either greater or less than the current FTEE allocation, and likewise for the Modifier's recommended level. An underlying assumption is that EBPSM, expert judgment-based models, and external norms are all "advisory" to the VA decision maker. Each provides some evidence for adjudicating appropriate physician staffing levels. Each will have its proponents and opponents. (For a clear indication of this, see the Conclusions generated by the study's six specialty and two clinical program panels in the appendix to this chapter.) Hence, the specification of parameter values in the Reconciliation Strategy is an administrative decision, in which the VA decision maker evaluates the strengths and weaknesses of the alternative approaches and renders a judgment about appropriate staffing in light of all pertinent information. The Reconciliation Strategy requires that these judgments (necessarily subjective in most cases) be made explicit, and the weighting parameters are devices for helping to achieve this. There are, in fact, two dimensions to this decision problem. Establishing Appropriate FTEE Targets, by Specialty and Program Area For each component of FTEE in Equation 6.1, the decision maker certainly could conclude that either the Empirically Driven Baseline or the Modifier

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Physician Staffing for the VA: Volume I estimate should be adopted in its entirety. However, there are plausible circumstances in which other conclusions may be more reasonable. For example, within a given specialty the FTEE estimates from both the PF and the IPF could seem too low, whereas those from both the SADI and the DSE could appear too high. In such a case, parameter values between 0 and 1 are logically required by the Reconciliation Strategy. That is, by appropriately selecting b, c, and d values within the 0-1 interval, the decision maker can arrive at an appropriate physician FTEE estimate. If each parameter is assigned a point value, all three FTEE components in Equation 6.1 will be uniquely determined, as will total FTEE for that specialty.1 If one or more parameters is assigned a range of permissible values, there will be correspondingly a range of permissible values for total FTEE. In the final section of this chapter, a numerical example is provided to illustrate the calculation of physician FTEE targets under various specifications of the Reconciliation Strategy. Establishing a Transition Policy to Phase in New Physician Staffing Levels It frequently would not be practical for a VAMC to realize instantaneously its new target level of staffing in a given specialty, if a change were identified by the Reconciliation Strategy. As the analyses by the specialty and clinical 1   Note that the physician FTEE levels emerging at any moment from the EBPSM and the expert judgment models are contigent on assumptions about the prevailing FTEE levels for nurses and other nonphysician personnel. If the FTEE levels for these nonphysicians are assumed to change, for whatever reason, calculated physician requirements may change accordingly. Because the PF, SADI, and DSE models all permit one to investigate the potentially interactive relationship between physicians (by specialty) and nonphysicians (by type), they permit physician requirements to be calculated conditional upon nonphysician FTEE levels. The IPF models, estimated here at the facility (not PCA) level, typically do not permit one to explore these interactive relationships (see chapter 4). Rather, there is an implicit assumption in these IPFs that as physician FTEE is adjusted in response to projected changes in workload, nonphysician personnel will be adjusted (by the VAMC)—as required—to maintain the physician-workload relationship purportedly captured in the estimated equation. As noted in chapter 4, this is one disadvantage of using the IPF within the Reconciliation Strategy. As suggested in chapter 7, there are good reasons why the VAMC might wish to consider changing physician and nonphysician personnel in concert in response to some projected change in workload. In particular, suppose the goal of the VAMC was to minimize cost, subject to the constraints that (1) patient workload demands must be met and (2) the quantity and mix of physicians (by specialty) and nonphysician personnel must be consistent with meeting or exceeding certain quality-of-care standards. Then, as the linear programming analysis in chapter 7 demonstrates, the FTEE levels of all inputs (explicitly being modeled) must be coordinated in order to produce an "optimal" staffing pattern.

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Physician Staffing for the VA: Volume I program panels suggest, this target could differ substantially from the current FTEE level. To illustrate, suppose there are now 8 FTEE physicians in a specialty at some VAMC and that the target level emerging from the Reconciliation Strategy is 12. To achieve this full 50 percent increase, at least four physicians will have to be recruited (given that each would contribute at most one FTEE to the VAMC). To accommodate this increase, there might need to be substantial expansions in staff, equipment, or space. The transition could not be accomplished immediately. Its net effect on the VAMC's budget could be considerable. In such instances, a policy of phasing in these FTEE targets permits the decision maker to achieve feasible, incremental changes in physician staffing. For example, if there are now 8 FTEE physicians in a specialty and the Reconciliation Strategy target level is 12, the VA decision maker might judge that an appropriate intermediate target is 10 FTEE, to be achieved (say) over the next 12 months. Factors at the VAMC that ought to influence either the level at which the intermediate target is set, the timetable for phasing it in, or both, include: The capability for acquiring adequate nursing, technical, and all other nonphysician personnel to complement the new level of physician staffing; The capability for acquiring the necessary space, equipment, and other physical resources; Whether the new physicians would be involved in program initiatives requiring, for viability, some critical mass of physician FTEE in that specialty; and Whether the proposed change in staffing levels from the current FTEE level affords a realistic opportunity for determining if the hypothesized improvements in access, quality of care, and other outcome variables do occur over time; that is, there may need to be some minimum increment in physician FTEE before one would expect to find measurable improvements in system performance. Hence, where there is a significant difference between the current staffing level and the target derived through the Reconciliation Strategy, the committee recommends that the VA consider phasing in the target by establishing an intermediate target. An intermediate target should not be viewed as a vehicle for making merely cosmetic or symbolic changes in staffing; rather, it is intended to be a level as close to the target as material considerations permit. The implication is that a VAMC should proceed toward its staffing targets as rapidly as possible, subject to resource and organizational constraints.

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Physician Staffing for the VA: Volume I These increments (or decrements) in staffing would provide the VA with natural experiments for analyzing prospectively and rigorously whether the new physician FTEE levels lead to the hypothesized changes in access to care, indicators of the quality of care, and other measures of system performance. Such evidence is critical in the development of a dynamic VA physician requirements methodology—one that evolves and improves over time. Using the Reconciliation Strategy to Calculate Physician FTEE Among the responsibilities assigned by the committee to each of its eight specialty and clinical program panels, the final and arguably most difficult was to render advice on three related issues: From the perspective of the specialties or VA program areas represented by the panel, is the committee's proposed Reconciliation Strategy a viable and appropriate mechanism for determining physician requirements? If so, what specific form should it take? That is, what should serve as the core empirically driven and expert judgment approaches to staffing from which the Baseline and Modifier terms in Equation 6.1 can be derived? What are appropriate values for the weighting parameters b, c, and d? What role should external staffing norms play? As an explicit part of the Modifier term? As supplementary data to lend perspective to the calculus of Equation 6.17 Or, because of interpretive difficulties, little role at all? For the specialties or activities within its purview, could the panel render an advisory judgment, either quantitatively or qualitatively, about whether physician staffing in the VA is currently appropriate? The panels' responses to these inquiries (and much more) are contained in their final reports to the committee, which are reproduced in full in Volume II, Supplementary Papers. These eight specialty and clinical program panel reports, taken together, constituted the principal advisory information available to the committee on how best to implement the Reconciliation Strategy, by specialty and VA program area. To put the committee's recommendations below in perspective, the Conclusions section from each of the eight panel reports is presented in the appendix to this chapter. For each panel, this excerpt has been supplemented with a table summarizing the physician staffing levels obtained in the relevant specialties for FY 1989 by applying the various methodological approaches developed in this study to three (or in the case of psychiatry, four) illustrative VAMCs.

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Physician Staffing for the VA: Volume I The committee's own recommendations about determining physician requirements under the Reconciliation Strategy, using the FTEE component definitions specified in Equation 6.1, are presented and discussed below. Total Physician FTEE (VA and Non-VA) for Direct Care, Resident Education, Administration, and Leaves The discussion of this major component of total physician FTEE (denoted by X in Equation 6.1) focuses on the following: (1) how its FTEE subcomponents ought to be derived, assuming either an empirically based or expert judgment-based approach to staffing; (2) the specialty and clinical program panel recommendations to the committee on how best to compute X; and (3) the committee's own recommendations about important aspects of this issue. (1) Computing the Subcomponents of X Within the Empirically Based and Expert Judgment Approaches. Consider the following FTEE subcomponents, in turn: Staff Physicians for Direct Care (all PCAs) Under an empirically based approach, these FTEE are derived from either the PF or the IPF models, using data from the CDR (i.e., the FTEE allocations to direct care), the Patient Treatment File (to obtain workload), and other secondary VA sources (see chapter 4). Under an expert judgment approach, these FTEE are derived from that part of either the SADI or the DSE that estimates physician time requirements across all PCAs. FTEE for resident education is jointly determined in the process (see chapter 5). Resident Education by Staff Physicians Physician FTEE are allocated to this subcomponent through the "Education and Training/Instructional Costs" line items in the CDR. [A minor, but unavoidable, complication is that those line items also reflect time devoted to training nonphysician staff.] In the IPF variant of the EBPSM, staff physician FTEE for resident education is added directly to direct-care FTEE to form the model's dependent variable. In the PF model, the resident education FTEE variable was typically not a statistically significant factor explaining workload and was not included in the final equations. Thus, when determining physician requirements under PF, the resident education FTEE applicable to a given specialty at a given facility must be added in separately; a reasonable approach is to use the most recently available estimate from the facility's CDR (see chapter 4).

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Physician Staffing for the VA: Volume I Under an expert judgment approach, there is no distinct estimate of FTEE for resident education in the PCAs. Rather, it is determined jointly with the FTEE required for direct care, as noted above. However, both the SADI and the DSE provide separate estimates of FTEE required for resident education in the classroom. On the other hand, the CDR's "Education and Training/Instructional Costs' line item, used in both EBPSM variants, is intended to represent staff physician FTEE allocated to resident training both in the PCAs and the classroom. Administration by Staff Physicians There is no general line item for administration in the CDR worksheets submitted by the physician-related cost centers at a VAMC. Instead, the time devoted to most administrative tasks, large and small, must be incorporated implicitly in FTEE estimates for other physician activities explicitly recognized in the CDR; the direct-care line items are the most likely repositories for administrative FTEE. [The one significant exception is that FTEE for "Education and Training/Administration," pertaining primarily to resident education, is collected explicitly and can be analyzed separately.] Hence, the physician FTEE variables used in both the IPF and the PF models include, as an implicit subcomponent, the time devoted to administrative tasks. In both expert judgment models, the time required for administration (by the service chief and all others) is estimated separately; there is an effort to keep these FTEE distinct from those devoted to patient care and resident education. Miscellaneous Other Staff Physician Activities There are a few CDR line items (e.g., District, Regional, or National Support) that do not fall under direct care, education, or research. They constitute a very small fraction of physician FTEE and do not lie within the purview of either the PF or the IPF model. Under either empirically based approach, FTEE for these miscellaneous activities must be estimated separately, then added to the FTEE estimated for all else to derive a total for staff physicians. A reasonable procedure for a given specialty or program at a given VAMC is to adopt the previous year's allocation of FTEE to these various activities. In the expert judgment models, there is no FTEE "residual" to estimate. Both the SADI and the DSE are designed to encompass a mutually exclusive and exhaustive set of mission-related activities. Leaves of Absence for Staff Physicians The committee acknowledges the various categories of leave to which VA staff physicians are entitled: annual, sick, administrative, and others. But it also appreciates that most VAMCs can adjust to these absences through the flexible scheduling of patients, other physicians, and nonphysician personnel.

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Physician Staffing for the VA: Volume I staffing level in ambulatory care consistent with the norm. The implied physician staffing level of each VAMC could then be compared with its actual staffing. In sum, the panel found these analyses interesting, but counsels caution in drawing policy inferences from them. The overall trend from applying these norms was as follows: Two VAMCs (I and II) appeared neither significantly overstaffed nor understaffed, whereas VAMC III's CDR total for ambulatory care was significantly lower than any of the norms suggested that it should be. The validity of these comparisons hinges on the validity of applying these externally derived visits/MD ratios to VA facilities, and the panel has several concerns in this regard. First, an outpatient "visit" is not a homogeneous concept but rather is defined specifically by the number, type, and severity of problems presented by the patient. In applying these norms (within the scope of this study), there was no way to control for this natural variability. Second, although the definition of a physician "FTEE" in the VA is relatively clear, this is not the case elsewhere. Hence, there will be some (unobserved, hard-to-correct) heterogeneity in the denominators of these staffing ratios, threatening the validity of the comparisons. Overall Adequacy of Physician Staffing in the VA For the three VAMCs studied at length, two (VAMCs I and II) were found (in FY 1989) to be understaffed according to all modeling approaches except the PF; VAMC III was significantly understaffed by all approaches. In the panel's judgment, this general pattern of results would likely be replicated if these modeling approaches were applied across the VA system. Speaking qualitatively, the panel feels that for the patient care that needs to be delivered, ambulatory care in the VA is presently understaffed. However, a sample of three is too small for drawing quantitative conclusions about the degree of understaffing systemwide. If a physician requirements methodology built around the SADI were to be applied to ambulatory care programs across the system, a quantitative assessment would be possible—and the panel's present judgment on staffing adequacy could be checked directly. Other Points Whatever physician staffing methodology the VA adopts should be reevaluated and updated on an ongoing basis. Given the anticipated changes in patient demographics, the technology of care, and physician practice patterns in the private sector, determining physician requirements in the VA cannot be a

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Physician Staffing for the VA: Volume I one-shot affair. A thorough reassessment of the methodology and required data should be undertaken at least every 5 years. Final Remarks For calculating physician requirements for the ambulatory care program at VAMCs, the panel supports the use of a Reconciliation Strategy whose FTEE components are analyzed as recommended above. The panel's estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above, are summarized in Table 6A.7. [Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

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Physician Staffing for the VA: Volume I TABLE 6A.7 Estimates of Physician Requirements in Ambulatory Care at Three VAMCs A. Total FTEE VAMC CDR PF DSE SADI Survey1 VAMC I 28.4 26.4 54.2 43.0 47.5 VAMC II 51.3 41.0 95.7 52.8 67.0 VAMC III 19.3 30.7 79.2 50.1 52.5 B. Direct Care Plus Resident Education FTEE Only VAMC CDR PF DSE SADI Survey1 VAMC I 21.32 19.02 27.9 21.8 N.A. VAMC II 47.83 37.53 52.9 29.9 N.A. VAMC III 9.14 30.54 52.4 35.1 N.A. 1 Panel median response to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE level at each VAMC. To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirically based approaches (as applicable), and from both expert judgment approaches. 2 Based on a systemwide average for medicine services in RAM Group 3, these figures assume that 74 percent of total education FTEE in ambulatory care is for resident education. 3 Based on a systemwide average for medicine services in RAM Group 5, these figures assume that 67 percent of total education FTEE in ambulatory care is for resident education. 4 Based on a systemwide average for medicine services in RAM Group 4, these figures assume that 61 percent of total education FTEE in ambulatory care is for resident education.

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Physician Staffing for the VA: Volume I LONG-TERM CARE PANEL As a framework for determining VA physician requirements in long-term care, the panel endorses a specification of the Reconciliation Strategy that can assess the FTEE needed for all extended care and geriatric services, not simply for nursing home and intermediate care beds. Regarding the components of the strategy, the panel recommends the following: Patient Care, Resident Education, and Administration For these activities, FTEE should be derived from expert judgment approaches rather than the EBPSM, for several reasons. First, the PF variant of the EBPSM allows one to infer physician requirements for the nursing home and intermediate PCAs, but those geriatric and extended care activities occurring on other PCAs are excluded from what the model calls "long-term care." For example, geriatric evaluation units (GEUs) are analyzed as part of the inpatient medicine PCA. Second, because the IPF is specialty specific and the long-term care (LTC) program is multidisciplinary, there is no IPF that applies to LTC. [However, the effect of nursing home and intermediate care workload on physician requirements is recognized in each IPF through the independent variable RUGWWU (Resource Utilization Group Weighted Work Units).] Third, an expert judgment model built around the SADI offers a flexible approach for evaluating physician FTEE requirements for all extended care and geriatric services. The current LTC SADI is designed to capture the FTEE of physicians whose dominant commitment is to the VAMC's LTC "service." But it would be straightforward to extend the SADI to include the FTEE of all physicians, regardless of specialty or dominant commitment, who devote time to extended care or geriatrics. Thus, the important role of psychiatrists and rehabilitation medicine physicians would be acknowledged. Research The amount of FTEE earmarked for research should be empirically driven, that is, based on a facility-or specialty-specific analysis of the existing relationship of research funding and other indicators of research activity to research FTEE. Hence, these research FTEE allocations would vary by facility and likely be a function of the facility's affiliation status.

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Physician Staffing for the VA: Volume I Continuing Education The panel recommends that there be a minimum amount of FTEE set aside for continuing education, perhaps pegged to state medical licensure requirements. In addition to this baseline allocation, the panel recommends that additional FTEE for continuing education be allowed for physicians in highly affiliated VA facilities or where significant research is ongoing. These physicians should be expected to present research findings and report on program developments at national meetings of the specialties in which they hold academic appointments. The effects of this allowance on total FTEE requirements should be estimated according to the level of affiliation and the amount of research funding at each facility. Leaves of Absence As a baseline across the system, the percentage of total FTEE allocated to leaves of all types should be set at a uniform level; the panel concurs with the committee that a reasonable benchmark is the amount of annual leave. However, there should be a mechanism to allow for leave days beyond this baseline for facilities that participate heavily in external research and education activities. An index for the latter would be the facility's affiliation status. Purchased Coverage for Nights and Weekends Assuming adequate support from medicine and the other services, no additional FTEE are required. Consulting & Attending and Without-Compensation Coverage Assuming the VAMC is appropriately staffed with VA physicians, there is, almost by definition, no need for additional C&A and WOC FTEE to meet basic needs. The panel notes, however, that these non-VA physicians can serve to improve the quality of patient care. External Norms For three VAMCs the panel computed what physician FTEE would have been had each been staffed with the same intensity, in turn, as three private-sector nursing homes, another VA nursing service, and to the level suggested by

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Physician Staffing for the VA: Volume I the VA's own rough guidelines published in 1965. The overall finding was that none of the three VAMCs was significantly overstaffed or understaffed (in FY 1989). The panel believes that these analyses suggest that staffing norms can be usefully applied in LTC. But two caveats should be noted. First, except for the old VA guidelines noted, these "norms" are simply a reflection of the staffing behavior of LTC units as they have evolved over time. Second, there is no universally accepted operational definition of an FTEE, so that these workload/FTEE ratios computed for non-VA facilities must be carefully interpreted. It is not clear, for example, to what extent a "full-time" physician in a given private facility has other outside responsibilities occupying significant portions of the work week. In general, it appears that private LTC facilities collect good workload statistics (e.g., admissions, patient days), but physician staffing data are less likely to be recorded in a standardized fashion. Overall Adequacy of Physician Staffing in the VA Given the small number of VAMCs examined in detail, the panel could make no determination about the overall appropriateness of staffing for LTC in the VA. To make a global determination, it would be necessary to apply the SADI across the VA system. The panel urges that this be done, and in a way sensitive to particular concerns that arise in LTC. For example, the SADI must indicate the extent to which physicians assigned to LTC (rather than medicine) have primary responsibility on intermediate medicine units, since this would have a major effect on the amount of time that LTC physicians must spend on these units. Similarly, the SADI must specify clearly whether physicians have a primary care role, or consultative/advisory role, in the operation of VA hospital-based home care (HBHC) units. Other Points The panel feels that there are at least seven issues requiring careful consideration as the VA continues to refine the proposed physician staffing methodology. Physician staffing requirements were not reviewed for HBHC because, under the current VA system, the program is implemented by nursing with little direct physician involvement for patient care. In the non-VA home care field, the push toward decreasing utilization of higher cost inpatient services has shifted the care of many patients to the community. This trend will be seen in the VA as well for the elderly and, perhaps, for AIDS patients. These veterans will

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Physician Staffing for the VA: Volume I have a higher acuity of illness than those currently being serviced by HBHC, and the rate of patient turnover will increase. Because of this, physicians will be more directly involved in the following activities: (a) screening for enrollment into HBHC, (b) patient care planning, (c) multidisciplinary care management, (d) periodic in-home assessment, and (e) evaluation of patient progress and potential for discharge from HBHC to other levels of care. Rather than contenting itself with current levels of physician activity in HBHC, the VA should review external VA norms to determine requirements for physician involvement in the future. The American Academy of Home Care Physicians will be a significant resource for this endeavor. Geriatric psychiatry is an area requiting particular attention. Although a high percentage of nursing home patients have secondary diagnoses involving mental disorders, psychiatrist time allocated to nursing home units appears to be disproportionately low. Additional analyses are required to determine whether this is merely a feature of the VA FTEE reporting system, or reflects a surprising lack of involvement of psychiatry in the treatment of these patients. (A similar question arises in other areas where geriatric psychiatry would be expected to play a significant role, e.g., HBHC, Adult Day Health Care, and Geriatric Evaluation and Management Units.) Of the LTC workload measures available to the panel, the one most closely correlated with patient acuity appears to be the RUGWWU scores, which are derived from the well-known Resource Utilization Group (RUG) methodology. Nonetheless, the panel strongly recommends that the VA determine the degree to which RUGWWU scores are predictive of physician, rather than nursing, activity. If the correlation is deemed inadequate, the search for better workload variables should continue. With regard to intermediate medicine units, the panel suggests that there are at least three different types of arrangements, and that the particular arrangement has an impact on the use of the physician and the amount of time that he or she may need to spend on the unit. These types of arrangements are: Distinct, identified units where the LTC physician is responsible for providing primary care; Distinct, identified units where the LTC physician has a consultative role only; and Not an identified or distinct unit but an arrangement in which intermediate care beds are dispersed throughout other services and in which the LTC physician has a consultative role only. With regard to training issues, the panel suggests that the involvement of medical students on long-term care units be explored in detail. For example: What is the usual number of students doing clerkships on a long-term care unit at one time? How long do such clerkships usually last? In how many VA

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Physician Staffing for the VA: Volume I facilities, and how often, are such clerkships operational? What demands does this place on long-term care physicians with respect to teaching and supervision? Are house staff allocations based adequately on the LTC needs of the VAMC? These same questions may need to be explored in relation to residents in different postgraduate years. Further, it is important to clarify the actual average time involvement of fellows assigned to long-term care units; for example, if a fellow is assigned "full-time" to a unit, how much time does this mean he or she generally spends per day on the unit? Another concern of the long-term care panel is the importance of nonphysician practitioners (NPPs) in the provision of LTC services. There is a need to distinguish between different responsibilities and functions of nurse practitioners relative to physicians assistants, and the differential impact of each of these types of NPPs on physician time requirements. (The surveys conducted by the nonphysician practitioners panel, discussed in Volume II, Supplementary Papers, shed some light on these questions.) The panel also stresses that all NPPs should have maximum flexibility in all long-term care activities, in order to ensure optimal use of physician time. One final and major point: Further iterations of the LTC SADI should have the capability of assessing physician time requirements for all of the following activities, defined by the VA's Office of Geriatrics and Extended Care as falling within its purview: Nursing home care (VA, community, state home) Domiciliary care (VA, state home) State home hospital care Hospital-based home care Community residential care Adult day health care Hospice/palliative care Respite care Geriatric Research, Education, and Clinical Centers Geriatric Evaluation and Management Units Dementia and Alzheimer's disease initiatives Information and referral services or activities Hence, the scope of "long-term care" activities in the overall physician requirements methodology would be operationally defined in an appropriate fashion and could encompass the growing role of physicians in such programs as HBHC. It is important to distinguish between geriatrics and long-term care, and to articulate the relationship between the two—demand for long-term care is not generated exclusively by geriatric patients, and geriatricians have responsibility for patients outside the long-term care setting.

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Physician Staffing for the VA: Volume I Final Remarks The panel urges the VA to adopt a form of the Reconciliation Strategy that uses expert judgment rather than statistical models to determine the amount of physician FTEE required for patient care, resident education, and administration within the LTC program of a VAMC. The remaining components of FTEE discussed above should be determined through a combination of empirically based and expert judgment-based approaches, as indicated. The panel's estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above, are summarized in Table 6A.8. [Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

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Physician Staffing for the VA: Volume I TABLE 6A.8 Estimates of Physician Requirements in Long-Term Care at Three VAMCs A. Total FTEE VAMC CDR3 PF3 DSE4 SADI4 SADI-Modified1, 4 Survey2, 4 VAMC I 0.7 0.3 2.3 3.2 1.3 2.5 VAMC II 1.6 1.3 2,7 3.1 2.4 2.5 VAMC III 3.3 3.1 3.0 3.3 2.5 3.0 B. Direct Care Plus Resident Education FTEE Only VAMC CDR3 PF3 DSE4 SAD4 SADI Modified1, 4 Survey2, 4 VAMC I 0.6 0.2 1.5 0.5 0.5 N.A. VAMC II 1.6 1.3 1.7 1.6 1.6 N.A. VAMC m 3.3 3.1 1.2 2.1 2.1 N.A. 1 Derived by replacing the SADI-based estimates for non-patient-care activities with estimates based on the DSE; all FTEE for patient care and resident training in the PCAs continue to be derived from the SADI. 2 Panel median response to the question, posed by mail survey in September 1990, of what is the overall preferred physician FTEE level at each VAMC. To provide a context for the response, each panel member was presented with a summary of the physician FTEE level emerging, alternatively, from the CDR, from both empirlcally based approaches (as applicable), and from both expert judgment approaches. 3 Does not include FTEE for consults by geriatricians to the non-LTC patient care areas, i.e., all PCAs except nursing home and intermediate care. 4 Does not include FTEE for consults by nongeriatricians to nursing home and intermediate care PCAs.

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