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Physician Staffing for the VA: Volume I 3 OVERVIEW OF THE ANALYSIS The tasks of defining, presenting, and evaluating the committee's proposed VA physician staffing methodology begin in this chapter. In what follows, major questions that must be resolved in constructing such a methodology are previewed. These questions include: Which existing types of models or algorithms for assessing manpower requirements, in general, can be adapted to determine the number of VA physicians required, by specialty grouping? Will these prove adequate, or will new modeling approaches be needed? For each approach, what are the appropriate sources of data and appropriate analytical procedures—both for statistical inference and decision making—for deriving physician staffing levels that would be consistent with high-quality care? Should physician requirements be determined on the basis of a single dominant approach, a menu of approaches, or a strategy that synthesizes several approaches? If the latter, how should such a synthesis be achieved analytically? Can the strategy for synthesis be sensitive to the concerns of each specialty, while allowing all specialties to be treated in a coherent, internally consistent fashion? Given a choice of strategy for calculating physician requirements, what management policies will enhance the likelihood of successful implementation as well as refinement of the methodology over time? In the remaining chapters, these questions are examined in some detail as the components of the methodology are developed piece by piece. The core elements of the methodology are presented in chapters 4 through 8; some important questions relating to VA physician requirements are examined in chapters 9 and 10; and the committee's main conclusions, including recommendations for additional analysis, are summarized in chapter 11.
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Physician Staffing for the VA: Volume I Before these questions are introduced and the suggestions for their resolution in the chapters ahead are discussed, the main product that is to emerge from this study is commented upon briefly. The VA physician requirements methodology involves statistical formulas that use existing VA data. It involves the use of expert judgment approaches to derive appropriate physician staffing. It can accommodate physician staffing guidelines emerging from outside the VA health care system (external norms). However, the overall methodology will not consist simply of statistical formulas, or expert judgment procedures, or external norm-based staffing ratios. Rather, it is best characterized as a decision-making process —a process for using these approaches, in concert, to establish physician staffing recommendations that are defensible by definable criteria. In what follows and in chapters 4 through 7, the choice among alternative analytical approaches, and of desirable physician Full-Time-Equivalent Employee (FTEE) levels, is assumed to rest in the hands of a stylized actor called the VA decision maker. It is recognized that decisions within a system as complex and diverse as the VA require the interaction and consultation of multiple individuals with a variety of perspectives at various sites throughout the system. In many cases there is no one individual either in the field or in the VA Central Office that can be identified as the decision maker on a particular issue. Recognizing that interactions among multiple actors are typical of decision making in large organizations, it is nonetheless a useful shorthand (which simplifies exposition) to personify this set of relationships and processes in a single "VA decision maker." The VA decision maker will alternatively appear to reside in Central Office or at a particular VAMC. In no case should this characterization suggest that the locus of decision making is assumed to reside exclusively in either site or that the decision maker is a pure type. Particularly in chapter 7, the importance of a strong, two-way communication link between the individual VAMCs and Central Office is emphasized. For the physician requirements methodology to function properly, and improve over time, certain kinds of information must flow freely between Central Office and the VAMCs. With this as background, the major methodological questions facing the committee are discussed below. A CENTRAL PROBLEM: DETERMINING PHYSICIAN FTEE REQUIRED FOR PATIENT CARE AND RESIDENT EDUCATION By far the most important and difficult question (within this study's purview) facing the VA decision maker is how to determine the number of physicians, by specialty, required to meet a VAMC's commitment to high-quality patient care and resident education.
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Physician Staffing for the VA: Volume I In the terminology of the study, this question can be stated more precisely as follows: What quantity of VA physician FTEE, by specialty, is required for rendering patient care and training residents at a given VAMC, given the availability and relative productivity of these residents (who interact with staff physicians in patient care and training), nurses, nonphysician practitioners, support staff, and other productivity-influencing factors? (The phrasing of the question acknowledges that the VA physician's roles as caregiver and educator are frequently intertwined and not always easy to disentangle empirically.) Three general approaches for determining physician requirements for patient care and resident education are analyzed in chapters 4 and 5. First, it is possible to construct statistical models relating physician FTEE to workload production rates, while controlling for factors that affect physician productivity. Once the models are estimated (by multivariate regression techniques), using existing VA data, one can derive the quantity of staff physician FTEE required to meet a given workload, conditional on assumptions about these factors—including the net effect of residents on workload productivity. Two complementary variants of these statistically oriented, "Empirically Based Physician Staffing Models" (EBPSM) are studied in depth in chapter 4: the production function (PF) and the inverse production function (IPF). There is a PF for each of 14 specified locus-of-care sites termed patient care areas (PCAs) in the VAMC; there is an IPF for each of 11 major VA physician specialty categories. Both variants allow physician FTEE requirements for patient care and resident education to be estimated on a specialty-specific basis at the VAMC level, and the PF permits this also at the PCA level. Second, physician requirements can be derived through an expert judgment approach, in which panels with clinical and staffing expertise are asked to determine the quantity of physician FTEE required to meet a specified workload, again conditional on resident availability and other factors. In chapter 5, two variants of this expert judgment approach are studied in depth, one based on the Detailed Staffing Exercise (DSE) and the other on the Staffing Algorithm Development Instrument (SADI). Both variants permit physician FTEE requirements to be calculated, by specialty, at the VAMC level and specific to PCA within the facility. A third approach is to develop physician staffing criteria based on standards, either explicit or implicit, established by selected non-VA providers of care. Such "external norms" can be used to derive point estimates of the physician FTEE required to meet VA workload or, alternatively, to establish the FTEE boundaries (ceilings and floors) for a range of acceptable staffing levels. In the course of its deliberations, the committee concluded that there are distinct organizational, economic, and methodological advantages in building a physician requirements methodology around the EBPSM—to the extent that the models' underlying clinical and statistical assumptions can be met. To the extent that these assumptions are not met, the EBPSM (or at least the FTEE
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Physician Staffing for the VA: Volume I recommendations emerging from them) should be modified, either by independently derived expert judgment assessments of physician requirements or by external norms, adapted to the case at hand. The EBPSM variants, relating physician FTEE to workload production, are grounded solidly in the reality of the practice of medicine—and of medical and administrative record-keeping—within the VA system. The data analyzed in chapter 4 collectively reflect the considered clinical judgment and resource allocation decisions of myriad VA health care providers, administrators, strategic planners, and budget managers. The assumptions underlying the validity of the EBPSM are noted in chapters 4 through 6. The standard statistical requirements for such multivariate regression models are summarized in chapter 4. Violation of these assumptions is cause for concern, of course. In addition, there are at least three other potential threats to the validity of the EBPSM. First, because of resource constraints, perverse incentives, less-than-ideal management, or other factors affecting the quality of care, historically observed FTEE-workload relationships at VAMCs across the system might be skewed from what they would be under less strained arrangements. If this were the case, the key input-output data used to estimate the PF and the IPF equations may not reflect high-quality medical care; hence, the prescriptions derived from those equations might not either. Second, the data relating FTEE to workload may be sufficiently poor (regardless of the quality of care itself) that serious biases are imparted to the statistical analyses. Third, physicians may be required for new programs or activities for which there are no existing, or appropriate surrogate, data. The presence of any of these problems (discussed in chapters 4 through 6) boosts the case for a physician requirements methodology that gives substantial emphasis to an expert judgment or external norm approach. Moreover, during the course of the study's many specialty and clinical program panel meetings, critics of the empirically based approach sometimes asserted that, at best, the EBPSM can indicate how to achieve a more efficient rearrangement of the current aggregate supply of VA physician FTEE. Thus, the question of whether additional physician FTEE would be required in aggregate is left unaddressed. In line with this intuitively reasonable claim is the following statistical fact, underscored in chapter 4: At a given slice in time, with a given distribution of workload to meet (and a given distribution of nonphysician resources and other factors) across the VA system, application of the IPF to a given physician specialty results only in a prescribed reallocation across the system of its current aggregate quantity of FTEE (for patient care and resident education, the FTEE components analyzed within the IPF). Put differently, if the IPF's prescribed FTEE reallocations were made, the net change in VA salary costs for physicians
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Physician Staffing for the VA: Volume I in that specialty would be close to zero. The zero-sum aspect of this result is literally built into the operating logic of the statistical technique (least-squares regression) used to estimate the IPF. Although this result does not strictly apply to the PF variant, it can be inferred (see chapter 4) that application of the PF across the system would likely lead to little aggregate change in total FTEE—given the current volume and distribution of workload. However, it does not follow that application of the empirically based approaches to derive future physician requirements for patient care and resident education implies a zero-sum, budget-neutral result. As vividly demonstrated in chapter 4, the level of projected workload plays an independent and potentially strong role in driving the physician requirements calculations. If workload for some future year is projected to rise from the present level, the prescribed quantity of physician FTEE will virtually always be higher than at present, all else equal, under either empirically based approach (or, for that matter, either expert judgment approach). If workload is projected to fall, so typically will physician requirements, all else equal. Hence, the argument that the VA decision maker should eschew the EBPSM because it automatically locks each specialty into its status quo position is misdirected. Rather, the decision maker's attitude about the EBPSM should be guided by whether the models' underlying assumptions are being met. It is worthwhile to rephrase the important ones now from a more positive perspective. Does the VAMC—in response to budgetary, manpower, and other constraints—attempt to maintain a balance between workload and physician FTEE so that staffing ratios are consistent with high-quality care? Are the PF and IPF equations properly specified, in terms of the explanatory variables included and their assumed mathematical relationship? Are the data, even if sometimes measured with error, sufficiently accurate on balance that statistically strong, clinically meaningful equations can be estimated? Can physician requirements for new programs or activities be inferred from PF or IPF equations estimated from existing data? To the extent that these questions are answered in the affirmative, the case is strengthened for a VA physician staffing methodology giving substantial weight to the EBPSM. As indicated in chapter 5, the committee's interaction with the study's eight specialty and clinical program panels has afforded ample opportunity to assess the merits of alternative orchestrations of an expert judgment approach. In sum, this study has generated compelling evidence that such panels can function effectively, even under significant time and information constraints. Using first the DSE and then the SADI variant, each panel was able to establish what it regarded as a reasonable range of physician staffing (in its specialty or program domain) in several actual VAMCs for which detailed data had been provided by staff.
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Physician Staffing for the VA: Volume I However, the committee's enthusiasm for a physician staffing methodology based solely on expert panels is tempered by several considerations. Compared with empirically based modeling, panels are administratively cumbersome and relatively expensive to operate. There is the challenge of defining a ''representative'' panel membership, then successfully appointing a group with the desired mix of clinical expertise, analytical sophistication, experience with the VA, and professional perspective. Some of the data required for the panel's staffing assessments are not collected centrally (at the moment) or are not stored in an automated fashion; in response, additional data would have to be gathered from each VAMC (see chapter 5). All of this leads the committee to the general policy position enunciated earlier. To determine physician requirements for patient care and resident education, the VA decision maker should rely on the EBPSM to the extent that the modeling assumptions are met; otherwise, substantial weight should be accorded to approaches based on expert judgment or external norms. DETERMINING PHYSICIAN REQUIREMENTS FOR OTHER MISSION-RELATED ACTIVITIES For each of these activities (and any residual miscellaneous ones), the principal methodological question that arose with respect to patient care and resident education resurfaces. Should physician FTEE requirements be determined through an empirically based approach, or expert judgment, or external (to the VA) norms, or some admixture of these? As the discussions in chapters 4, 5, and 6 (especially the latter) indicate, the choice in each case is typically between some form of data-driven FTEE allocation that may or may not be related to current staffing levels, and an expert judgment-derived FTEE allocation that need have no connection to the current level. To be specific, consider research. One empirically based approach is to "allocate" research FTEE to VAMCs in the future on the basis of current allocations—a type of pass-through arrangement. Another empirically based approach is to allocate these FTEE to VAMCs on the basis of their demonstrated research productivity, perhaps tying the allocations to the volume of research dollars generated in recent years. An alternative, expert judgment approach would distribute these FTEE on the basis of the percentage of time that VA physicians should be devoting to research, as appraised by the panels. A similar problem arises with continuing education. Future FTEE allocations could be based on current FTEE devoted to continuing education. Or, these allocations could be based on the time commitment required to qualify for specialty recertification or other credentials established by the profession—hence, an application of external norms to determining required
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Physician Staffing for the VA: Volume I FTEE. A third approach would rely on expert judgment to determine the amount of physician FTEE that ought to be devoted to continuing education. RECONCILING THE APPROACHES As discussed at length in chapter 6, the committee examined four alternative decision strategies for using these staffing approaches, singly or in combination, to derive total physician FTEE, by specialty, required for a given VAMC. To summarize, the strategies are as follows: For each specialty (e.g., medicine) or program area (e.g., ambulatory care), adopt one dominant approach (e.g., the PF variant of the EBPSM or an expert judgment approach using the SADI). Use two or more approaches in conjunction to derive a range of physician staffing estimates. Use two or more approaches in conjunction to derive a range of physician staffing estimates, whose budgetary and management implications are then examined through various sensitivity analyses. 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. The sensitivity analyses proposed in (C) would be pursued as well. As an overall framework for determining VA physician requirements (given workload and other factors), the committee endorses a variant of (D) in which the major components of physician FTEE are analyzed separately, then combined to produce the total FTEE required, by specialty or program, at the VAMC. This variant of (D) is termed the Reconciliation Strategy. The three components of physician FTEE consist of a major category (labeled simply "X" in chapter 6) that includes all patient care, resident education, administration, and leaves of absence; research; and continuing education. Together, these components are intended to represent a mutually exclusive and exhaustive categorization of how a physician's time is allocated at a VAMC. To execute the Reconciliation Strategy, for a given specialty or program at a VAMC, is to determine for each physician FTEE component: The most appropriate empirically based estimate of FTEE; The most appropriate expert judgment-based (or, alternatively, external norm-based) estimate of FTEE; and The most appropriate relative weight accorded to each in a simple formula (see Equation 6.1) for deriving a recommended FTEE level (or range of levels) for this component.
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Physician Staffing for the VA: Volume I The calculations are repeated for each of the three FTEE components, the results are summed, and what emerges is total physician FTEE requirements for the specialty or program. As envisioned, all of these choices, which effectively determine the outcome of the Reconciliation Strategy, rest with the VA decision maker. Put differently, the strategy is basically a framework, or shell, for organizing and analyzing data in a way that facilities policy analysis and decision making. In the committee's proposed physician requirements methodology, the formulas guide—they do not govern. However, it should be emphasized that they guide in very specific ways. The empirically based and expert judgment-based estimates establish the boundaries of the FTEE range within which the VA decision maker is supposed to choose. The Reconciliation Strategy is intended to be flexible, but it does impose restrictions on the range of FTEE that ought to be recommended. Regardless of exactly how the Reconciliation Strategy is executed, the resulting FTEE recommendations can be regarded as fair, or equitable, in the following sense: Suppose there were two VAMCs that were similar in all significant respects and suppose the projected workload for each was identical. Then, the Reconciliation Strategy would almost certainly lead to an identical set of physician FTEE recommendations for the two VAMCs. If the projected workloads differed, all else equal, the physician FTEE recommendations would now differ (in the same direction as workload). If, on the other hand, the projected workloads were identical but the two facilities were now assumed to differ in important ways (e.g., resident availability, support staff, affiliation status), the recommended physician FTEE levels would likely differ, also. In other words, the methodology attempts to treat VAMCs that are equally situated in an equal fashion, while according differential treatment to those that are differently situated. These anticipated outcomes are consistent with the principles of "horizontal" and "vertical" equity, cornerstone concepts in discussions about fairness in economics (Musgrave and Musgrave, 1989). MANAGEMENT USES OF PHYSICIAN STAFFING MODELS If the proposed methodology were adopted, the allocation of physician FTEE across the VA system would become more centrally directed. At present, each VAMC determines its own physician staffing levels, both overall and by specialty, subject to constraints established by its centrally assigned budget and ceiling on total personnel. The committee believes that the methodology has a much greater chance of influencing physician allocation decisions if it is integrated directly into the VA budgeting process, and it recommends (in chapter 7) that this be done.
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Physician Staffing for the VA: Volume I However, for the methodology to be implemented successfully, and to improve over time, there must be strong channels of communication between VA Central Office and the individual VAMCs, as noted earlier. If facilities have the opportunity, if not mandate, to respond to the methodology's recommendations (before they are implemented), several positive results will follow. More information relevant to physician requirements will be brought to bear than can (or should) be accommodated in any formal model. Better staffing decisions will result than if the methodology were applied mechanistically. Acceptance "in the field" will be greater than if allocations are obviously imposed. This proposed dialogue is oriented around the interpretation and evaluation of formal models. Such models allow all parties to the decision process to pose important "what if" questions that lead to better policy applications of the models—and to improvements in the models themselves. In chapter 7, the committee discusses how these analyses would be facilitated if the methodology were a part of a larger VA "decision support system" that integrated resource planning and budgeting. PROJECTING FUTURE VA PATIENT WORKLOAD Estimates of future physician requirements hinge crucially on estimates of future patient workload. The derivation of these workload estimates is the subject of chapter 8. The models adopted by the committee for projecting inpatient, ambulatory, and long-term care workload have several noteworthy features: In their structure and logic, all three represent adaptations of existing workload projection models used presently in VA strategic planning. The major difference in each case is that workload is expressed here in the form of a "weighted work unit" index (see chapter 4) rather than in terms of patient days or visits, as in the VA models. The models presented in chapter 8 explicitly adjust projected workload for anticipated changes in the age structure of the veteran population over time. They could be adapted readily to adjust also for changes in the distribution of the veteran population by gender or eligibility-for-care categories. The workload projections derived from these models can be input directly into both the PF and IPF variants of the EBPSM to derive future physician requirements, by VAMC and PCA within each VAMC. Although these workload projections are not directly applicable to the expert judgment staffing models, the committee demonstrates how they can be used to obtain indirect estimates of workload at the level of specificity required by the SADI and the DSE.
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Physician Staffing for the VA: Volume I The precision, specificity, and statistical validity of workload estimates could be improved if they were derived from patient demand functions that allowed the VA to predict system utilization as a function of such factors as veteran income and insurance status, as well as age and gender. THE VAMC-MEDICAL SCHOOL AFFILIATION RELATIONSHIP The committee's views on the present and future role of affiliations between VAMCs and non-VA medical institutions are presented in chapter 9. The committee concludes that the present affiliations "model," which links the VAMC to a medical school in a set of sharing agreements oriented heavily toward tertiary care, continues to bring very positive benefits to veterans. Such relationships appear to improve the recruitment and retention of high-quality physicians and to increase the veteran's access to state-of-the-art tertiary care. These affiliations are also integral to the VA's accomplishing two aspects of its mission—education and research. At present, 134 of the system's 172 VAMCs are affiliated. Because the committee is convinced that these benefits are substantial, it urges the VA to explore strategies for developing and expanding affiliations. It is understood that establishing a new affiliation is not always easy and requires the conscientious commitment of two complex institutions. However, the committee believes that equity and efficiency would be served if every VAMC were affiliated. Given the changing demographic structure of the veteran population—with the implied shifts in the nature of patient workload presenting at VAMCs—the committee believes that the VA should develop innovative affiliation arrangements that emphasize patient care, education, and research related to the chronically ill. These innovative models would be oriented around, and give emphasis to, ambulatory and long-term care. In recommending this, the committee urges the VA not to reduce its commitment to existing affiliation relationships, unless demographic shifts or reductions in patient workload so dictate. Rather, it encourages the VA to nurture affiliations across the board as a primary means for promoting access to high-quality care for veterans. NONPHYSICIAN PRACTITIONERS AND VA PHYSICIAN REQUIREMENTS In chapter 10, the committee presents recommendations about the present and future role of four particular types of nonphysician practitioners (NPPs):
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Physician Staffing for the VA: Volume I physician assistants, nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists. If certain specific changes were made in the way the VA collects FTEE data on NPPs, these providers could be integrated directly into the EBPSM in ways not possible at present. Similarly, both the SADI and the DSE expert judgment models could be modified readily to incorporate NPPs with greater specificity than presently. If these steps were taken, it would be possible to derive physician requirements conditional upon the assumed availability, and productivity, of each type of NPP, using either an empirically based or an expert judgment approach to the computations. Hence, the physician staffing recommendations emerging from the Reconciliation Strategy would be conditional on the assumed distribution of NPPs at the VAMC. Continuing education on the use of NPPs should be provided to VA physicians, and to the nonphysician practitioners themselves, on an ongoing basis. National guidelines on the use of NPPs should be strengthened where they exist, established where they do not, and updated on a regular basis over time. They should be orchestrated in a way that allows adequate flexibility at the local level for innovation and quality control. To promote the development and diffusion of new information about the appropriate use of NPPs, the VA should support research projects that examine the range of activities now performed by these practitioners across the system. The focus should be on innovative uses of NPPs that hold promise for increasing access to care while not compromising quality. COMMITTEE CONCLUSIONS AND RECOMMENDATIONS In the report's final chapter, the committee summarizes all of its conclusions and recommendations to the VA. Among these are specific proposals for testing, refining, and extending the physician requirements methodology so that it will improve over time. In the years ahead, a number of factors affecting the empirical validity of the methodology will change, at varying rates: the mix and acuity level of cases presenting at the VAMCs, medical technology, practice patterns, the scope of services offered by the VA, and the kinds and quality of data relevant to the models. Thus, it is important that the physician requirements methodology not be regarded as a static product; as the VA health care system changes, the methodology must adapt accordingly. The committee believes that its proposed approach is flexible enough to accommodate a variety of alternative scenarios.
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Physician Staffing for the VA: Volume I REFERENCE Musgrave, R.A., and P.B. Musgrave. 1989. Public Finance in Theory and Practice. 5th ed. New York: McGraw-Hill.
Representative terms from entire chapter: