Physician Staffing for the VA: Volume I (1991)

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.)

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:

1. 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.

2. 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.

3. 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?

Clearly, there are many such inquiries that relate physician staffing to budget.

4. 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.

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

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.

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).

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.

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.

For each component of FTEE in Equation 6.1, the decision maker certainly could conclude that either the Empirically Driven Baseline or the Modifier

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.

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

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.

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.

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.

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.

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).

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.

In the EBPSM, this issue resolves itself, in a sense, because the CDR-recorded FTEE level in a specialty presumably reflects the total requirements for staff physicians after allowing for the effect of leaves of absence on productivity. Thus, under the behavioral and data-related assumptions imposed by such models (see chapters 3 and 4), there is no need to adjust either the PF or the IPF for leave-related productivity losses.

But explicit adjustments are required in the expert judgment models. In both the SADI and the DSE, the FTEE estimates that emerge from simply summing the time required for all physician activities make no allowance for leave-related losses. In response, both instruments elicit separate judgment about the appropriate percentage of total FTEE to be devoted to leaves of all types.

After reviewing the issue, the committee concludes the following: The panels' various leave-time assessments (see Volume II, Supplementary Papers) are generally defensible. But, given the typical VAMC's ingenuity at flexible scheduling, to translate all potential hours of physician leave into an equivalent loss in FTEE is to overstate the true loss in physician productivity—and thus to overstate the FTEE supplement required to compensate for the loss.

In response, the committee recommends that, in the expert judgment staffing models, the leave component of total physician FTEE be calculated as the FTEE equivalent of the annual leave to which the VA physician is entitled.

Currently, full-time VA physicians earn 30 days of annual leave per year. Part-time physicians accrue annual leave at a rate of 1 hour per 13 hours worked; for example, a half-time ("4/8") physician would earn 80 hours (or 20 half-days) of annual leave per year. Hence, the fraction of total FTEE that could be allocated to annual leave is about 0.12 for full-time physicians and 0.08 for part-time. It follows that the "average fraction" of total FTEE allocatable to annual leave is f(0.12) + (1 -f)(0.08), where f is the proportion of full-time physician FTEE in total physician FTEE.

The procedure for upwardly adjusting expert judgment-derived FTEE to allow for annual leave is as follows: Suppose the derived total for all mission-related activities is T and that f is defined as above. The adjusted total FTEE for full-time physicians is fT/(1-0.12). For part-time physicians, the adjusted total is (1 -f)T/(1-0.08). In the illustrative calculations in the last section of the chapter, the intuition behind the formulas is demonstrated. Although the committee realizes that not all VA physicians elect to use the full leave to which they are entitled—in many cases, because of work demands—it does not wish to build this downward bias into the physician requirements calculations.

Contract Physicians As noted in chapter 4, FTEE estimates for physicians under contract to the VA are not available in the CDR but have been estimated in recent years through a systemwide survey.

Given the assumptions of the EBPSM (see chapters 3 and 4), staff and contract physician FTEE are basically additive; both are valid parts of total

FTEE at the VAMC. In the IPF model, the dependent variable includes contract physician FTEE for all specialties in which it is a nontrivial fraction of total FTEE. Hence, staffing predictions derived from the IPF are able to reflect jointly the required FTEE for staff and contract physicians taken together.

In the PF model, a variable for contract physician FTEE can be included on the right-hand side as an hypothesized determinant of workload production. In fact, such contract variables were rarely statistically significant and were omitted from the final versions of these PF equations. (This is not a surprising result since the specialties for which contract FTEE play the largest role, e.g., anesthesiology, laboratory medicine, diagnostic radiology, have no associated production functions.)

The patient care and resident education FTEE estimates from the expert judgment models are intended to be comprehensive assessments of physician requirements, irrespective of the particular mix of VA staff and contract physicians. (In fact, the SADI and DSE instruments purposely never distinguish between these two.) Thus, when using these approaches, no separate adjustment is required vis à vis contract physicians.

Purchased Physician FTEE for Night and Weekend Coverage Although there are particular PCAs in particular VAMCs where additional physician FTEE are hired to handle patient care during evening and weekend hours, the committee infers that typically this coverage is provided by a combination of residents and existing staff physicians assigned on-call duties. The major exception appears to be the emergency and admitting areas within the ambulatory care program, where around-the-clock physician coverage is the norm.

Thus, the committee recommends that when computing physician requirements through either the SADI or the DSE expert judgment approach, additional FTEE for off-hour coverage be incorporated only for the emergency and admitting & screening functions of ambulatory care.

In recommending this conservative approach within the expert judgment models, the committee urges the VA, in its subsequent evaluations of the overall methodology, to target this issue for special attention. The focus should be on whether VAMCs with relatively small services or few residents should be allocated additional FTEE for off-hour coverage in order to provide a reasonable work schedule for its staff physicians.

On the other hand, for either the PF or the IPF variant of the EBPSM, hours purchased for nights and weekends are already implicitly included in FTEE estimates to the extent that these hours are provided either by staff physicians (whose FTEE are already in the CDR) or by contract physician (see chapter 4). Hence, no further FTEE adjustments to either empirically based model is required to account for night and weekend coverage.

Consulting and Attending (C&A) and Without-Compensation (WOC) Physicians Without exception, the specialty and clinical program panels noted that C&A and WOC physicians enhance the quality of clinical and education programs at the VAMC. But whether these non-VA providers ought to be factored explicitly into the physician requirements calculations depends on whether an expert judgment approach or an empirically based model is being used.

The patient care and resident education portions of both the SADI and the DSE are designed for deriving total physician requirements, irrespective of whether services are rendered by in-house staff or outside consultants. The C&A and WOC estimates computed (in a second procedural step) under either expert judgment approach refer expressly to physician support desired, as a quality enhancement, over and above that required to meet day-to-day patient care and teaching responsibilities.

Given the logic of the staffing exercises, to add these desired non-VA FTEE to the quantity already asserted as the total for patient care and resident education may serve to overstate physician requirements.

Because of data limitations, C&A and WOC FTEE are omitted entirely from both the PF and the IPF variants of the EBPSM (see chapter 4). Information on the hours contributed by these non-VA physicians is not collected routinely at any VAMC. There are several related implications.

First, if C&A and WOC contribute significantly to workload in a given specialty and VAMC (all else equal), actual workload may exceed predicted workload in PFs for PCAs where that specialty has a significant presence. Similarly, actual (measured) FTEE may be less than predicted by that specialty's IPF. Such results would reflect the ''omitted variable'' bias discussed in chapter 4.

Second, to get a valid estimate of total physician staffing requirements in such a situation, one would want to add in sufficient FTEE to account for the productive contributions of C&A and WOC physicians. An empirically based inference about the latter could not be derived from either the PF or the IPF model but would have to come from another source—such as the VAMC itself. The C&A and WOC survey conducted by the study's affiliations panel demonstrates the feasibility of collecting this information by specialty within the VAMC (see Volume II, Supplementary Papers).

(2) Specialty and Clinical Program Panel Recommendations on FTEE for Component X. The panels analyzing the specialties of laboratory medicine, neurology, nuclear medicine, radiation oncology, diagnostic radiology, rehabilitation medicine, spinal cord injury, and surgery all recommended that the FTEE target for this component be derived from application of the SADI.

Likewise, the ambulatory care and long-term care panels endorsed the SADI for this purpose. In Equation 6.1, this is tantamount to setting b = 1.

The medicine panel concluded that the PF variant of the EBPSM ought to be the basis for estimating staff physician FTEE for the patient care subcomponent of X. Additional facility-specific data would be required to capture (1) FTEE devoted to resident education and miscellaneous activities and (2) other FTEE not in the CDR and, hence, not in the PF. Included in the latter are FTEE representing contract physicians and C&A and WOC physicians. This empirically based orientation implies b = 0 in Equation 6.1.

For psychiatry and anesthesiology, a (nontrivial) weighted-average version of the Reconciliation Strategy was invoked to derive FTEE targets. With the IPF and the SADI as the designated core approaches establishing the FTEE boundaries of the weighted average, an overall b value of about 0.35 appeared reasonable in psychiatry; for anesthesiology, b ranged from 0.38 to 0.49, depending on the VAMC being staffed. Both the psychiatry and the surgery panels emphasized that these particular estimates emerged from an analysis of only a few VAMCs (four and three, respectively); a different sample of sites might have yielded different assessments of the weighting parameter.

Each panel regarded its analysis of external norms to be of some interest but sufficiently weakened by data difficulties to preclude inclusion in the Reconciliation Strategy calculus.

(3) Committee Conclusions About FTEE Component X. The six specialty and two clinical program panels have demonstrated on a small scale the types of analyses that the VA decision maker ought to undertake to determine physician requirements across the system for this important component of FTEE. For each VAMC studied in depth, the current physician staffing level (including physician FTEE not in the CDR) was noted; the PF and the IPF variants of the EBPSM were applied; and the DSE and SADI expert judgment models were brought to bear. Only after considering the current FTEE level and the empirically based estimates and the expert judgment-based estimates did each panel reach a conclusion about appropriate staffing methodology.

Although the panels' conclusions varied, all eight groups operated within the framework of the Reconciliation Strategy; so should the VA decision maker. However, the main purpose of these panel deliberations and analyses was to develop a methodology—not to implement it. When the Reconciliation Strategy is applied to a significantly larger sample of VAMCs, there will exist the breadth of empirical information required to reach generalizable conclusions about whether the PF, the IPF, the DSE, the SADI, or some weighted combination of these is preferred for a given specialty or program area.

Each panel arrived at its positions through well-defined processes (see chapter 5). The committee believes that the panels' recommendations provide

the best available insights into how VA physician staffing levels should be calculated. But, as new methodologies are applied to an expanded sample of VAMCs, new data will emerge—and with them, additional insights about determining how to determine physician FTEE.

A study of the panel analyses suggests the following technical points germane to future applications of the Reconciliation Strategy:

• The PF and the IPF are potentially complementary variants of the EBPSM (see chapters 4 and 7), and either is a viable candidate for helping generate the Baseline estimate for patient care, resident education, administration, and leaves in Equation 6.1.

The PF allows physician FTEE to be derived by PCA within the VAMC, while taking explicit account of the productive contributions of residents and nonphysician personnel. The degree to which these substitute for VA staff physicians can be examined.

However, an acceptable PF cannot be estimated for specialties lacking a well-defined PCA (see chapter 4). Hence, for laboratory medicine, diagnostic radiology, nuclear medicine, radiation oncology, and anesthesiology, no PF model is presented.

In addition, physician FTEE is acknowledged in the PF model only to the extent that it is associated with the production of workload. If a given specialty renders care on a given PCA but is not shown statistically to contribute to patient throughput, that specialty's FTEE variable will not be included in the PCA's PF—even though it may have contributed significantly to the quality of care. When total required FTEE for that specialty is subsequently derived for the facility, none will be shown associated with that PCA.

The IPF (as specified in this study) generates a more direct estimation of physician requirements at the facility level; because of this higher level of aggregation, it is less vulnerable than the PF to measurement errors due to misclassification of FTEE within the VAMC's CDR. The IPF permits statements about statistical confidence to be constructed around physician FTEE predictions (in contrast to the PF, which permits confidence statements about the workload expected from a given set of physician and nonphysician inputs).

However, no acceptable IPF model can be estimated for VA PCAs that are multidisciplinary. Hence, there is no IPF presented for either ambulatory care or long-term care. Moreover, physician-nonphysician substitution relationships cannot be inferred from the facility-level IPFs reported in chapter 4.

In contrast to the PF, the IPF acknowledges all FTEE recorded in a given specialty at the VAMC regardless of the degree to which it is associated with the production of workload. In fact, the workload variables were statistically significant in all estimated IPF models (see chapter 4); but if that had not been the case for a given specialty's IPF, that equation would still tend to prescribe a nonzero amount of FTEE for that specialty at a given VAMC.

The IPF permits examination of actual-versus-predicted physician FTEE, by specialty, at a given VAMC, whereas the PF permits analysis of actual-versus-predicted workload, by PCA, at that same VAMC. Hence, the IPF and the PF can provide complementary insights into the relationship between workload and the physician staffing required to meet it (see chapter 7).

• To derive expert judgment FTEE estimates for use in the Modifier term in Equation 6.1, the most promising approach is a methodology built around the SADI.

The specialty and clinical program panel analyses indicate, in sum, that it is feasible to develop SADIs for all specialties and VA program areas. Likewise, it is possible to derive physician task-time estimates exhibiting strong face validity and yielding physician requirement totals for the VAMC that are generally plausible and acceptable to panel participants (see chapter 5 and the appendix to this chapter).

Although a methodology structured around the DSE would likely prove to be an excellent vehicle for examining staffing at an individual VAMC, there are several advantages to the SADI. Because the SADI focuses on the time required by physicians to perform specific tasks and functions, it is particularly suitable for the procedure-oriented specialties and compatible with all specialties. These task-or function-time estimates can be periodically reassessed, either through additional expert judgment, observations from time-motion studies, or both.

Like the DSE, the SADI permits the derivation of physician FTEE requirements for VA programs, services, or procedures that are either in the planning stage or sufficiently new that valid empirical data are not available (e.g., a hospital-based home care program in which the physician has substantial responsibility for patient care as well as administration).

Because DSEs would have to be individually crafted for each VAMC assessed, applying this instrument across the system would be labor intensive—perhaps requiring an ongoing set of expert panels working periodically to evaluate physician FTEE facility by facility. Reevaluating and revising the SADIs periodically would also require data analyses involving experts, but the overall resource commitment by the VA would be far less than with the DSE approach (see chapter 5).

Consistent with the views of virtually all of its specialty and clinical program panels, the committee recommends the following: The VA, without delay, should apply the SADIs either across the board or to a representative sample of VAMCs; analyze the results; revise the instruments on the basis of what is learned; reapply the SADIs to VAMCs across the system; and, finally, integrate the resulting FTEE estimates into a Reconciliation Strategy-based assessment of physician requirements via Equation 6.1.

• Regarding parameter b, denoting the relative weight accorded the Empirically Driven Baseline versus the Modifier in the Reconciliation Strategy, the committee recommends that it be determined on a facility-specific or facility-group basis. This contrasts with a policy of establishing, for each specialty, one value of b (or one range of values) to be applied to all VAMCs.

At any point in time, facilities will differ substantially both in how well staffed they are relative to the system norm and in the accuracy of the CDR data allocating physician FTEE to activities and PCAs. Allowing b to vary gives the VA decision maker the flexibility to translate knowledge of such local factors into the overall determination about the relative emphasis accorded the Baseline and the Modifier terms in Equation 6.1.

As discussed in chapter 7 and elsewhere in this report, any staffing model will offer, by definition, a simplified representation of a complex reality. Not all factors pertinent to staffing at a given VAMC will be incorporated, and there is no built-in safeguard to detect or correct many data measurement errors.

Thus, it is important that the VA decision maker be alert to idiosyncratic factors affecting physician requirements. It is also important that efforts to adjust for these factors not be ad hoc, but rather be achieved through a process that is systematic, understandable, and reasonable. The Reconciliation Strategy, with its capability of weighting the alternative approaches to staffing in terms of their perceived applicability, is a vehicle for implementing such a process in the VA.

With the discussion of the dominant component (X) of the Reconciliation Strategy complete, a discussion of the remaining two components of physician FTEE def'med in Equation 6.1 begins. The committee's recommendations below apply, with the necessary adjustments, to all specialties and both clinical program areas (ambulatory and long-term care) studied.

The committee's decision here was premised on the following principle: The amount of research FTEE built into overall physician requirements should be related to measurable indicators of research productivity and excellence. Not all VAMCs merit the same level of research FTEE.

Possible indicators—all potentially computable at the facility level and also by specialty—include the amount of VA and non-VA research funding obtained, the quantity of peer-reviewed papers published in scholarly journals, the number of VA "career investigator" award recipients on staff, or (most simply) the amount of FTEE currently allocated by that specialty to research in the VA's CDR. A variation on the latter, rejected by all panels, would allocate to each specialty at each VAMC a research FTEE total equal to the mean level for that

specialty in "similar" facilities, e.g., those belonging to the same RAM group (for a definition of the latter, see chapter 4).

Adopting any such empirically driven approach to determining research FTEE in the Reconciliation Strategy implies that c = 0 in Equation 6.1.

In principle, the committee's preferred approach is to link research FTEE earned to dollars of research support raised. This could be accomplished through specialty-specific statistical analyses taking the following general form: R₁ = f(VA Research Dollars Raised, Non-VA Research Dollars Raised, Specialty-Specific Characteristics, Facility-Specific Characteristics). Once estimated, the model could be used to derive the expected amount of research FTEE, , for a given specialty at a given VAMC as a function of right-hand-side variable values specific to that specialty and VAMC.

A significant limitation, however, is that data presently available systemwide can link research dollars (by funding source) to facility, but not to specialty or program area within the facility. If funding data were collected annually for each VAMC by cost center, specialty-specific models could be estimated directly. (Multidisciplinary research would have to be analyzed in a somewhat more elaborate model that accommodates two or more specialties simultaneously.)

Until the appropriate data emerge, the committee recommends an interim approach in which the VA decision maker allocates research FTEE by specialty on the basis of the specialty's currently reported research FTEE level.

The validity of either this interim approach or the committee's preferred policy of linking research FTEE to research dollars is affected by the accuracy of the CDR. Steps for achieving better FTEE allocations across activities (direct care, education, and research) as well as PCAs are proposed in chapter 11.

Continuing education for staff physicians should be an important component of any VA quality assurance program. The committee therefore recommends that a certain minimum amount of FTEE for continuing education be expected for all specialties at all VAMCs.

As with research, establishing the appropriate commitment to continuing education constitutes a VA policy decision that must balance many factors. The committee proposes that the minimum commitment for any VA physician be no less than 60 hours per year—the time-equivalent of what the American Medical Association requires as qualification for its Physician Recognition Award for Continuing Medical Education (American Medical Association, 1986). This translates into about 0.03 FTEE per full-time physician.

The committee regards this as a bare minimum, however, and believes that a higher floor allocation—for example, 80 hours per year—is both defensible and feasible. This would translate into about 0.04 FTEE per full-time physician.

If one regards these minimums as "expert judgment" driven, then it is as if d = 1 in Equation 6.1.

Without exception, the specialty and clinical program panels concluded that the non-VA staffing criteria developed in this study were of limited usefulness in determining VA physician requirements. After reviewing these external norm analyses, the committee concurs.

Most analyses involved the application of simple staffing ratios—e.g., patient days/physician FTEE (for inpatient and long-term care) and patient visits/physician FTEE (for ambulatory care)—to determine the implied level of appropriate physician staffing at the illustrative VAMCs examined in this study. These ratios were either published or directly computable from published data (e.g., Department of Defense criteria) or else were inferred from observed staffing patterns at selected non-VA treatment sites.

In most instances, applying these simple ratios to derive VA FTEE levels was technically straightforward. But across specialties and program areas, there were recurring concerns:

• Comparability of patients. The ratios were computed for patient populations that frequently differed from VAMC patients in age, gender, and other more specific indicators of case acuity. Moreover, it is simply not possible at most facilities to determine from existing data how much physician time is devoted to treating the VA-comparable portion of total patient workload. Similarly, these ratios could not control for differences in the complexity of cases and intensity of care required between the non-VA and VA populations.

• Definition of physician FTEE. In contrast with the VA, most non-VA facilities do not measure physician time in terms of full-time equivalents. There is little need to, since physicians are typically not paid from a central budget but participate in patient care and educational activities as "attending" physicians with varying time commitments to one or more institutions. Hence, there is a risk that the denominators of the staffing ratios (for a given specialty and PCA) were not measured comparably.

• Appropriate incentives. In this era of tight budgets, observed staffing in private hospitals and clinics—particularly those that are for-profit—will reflect a special concern about controlling cost. This may be achieved through efforts to manage case mix or the resources allocated to treat patients, regardless of the level of severity. In the absence of countervailing pressures (either competitive,

regulatory, or peer-imposed), this can lead to inappropriately lean physician staffing. (This is not to imply, of course, that the private sector is under necessarily greater financial constraints than the VA.)

• Policy relevance of observed staffing behavior. With the exception of criteria derived from the Department of Defense, the Indian Health Service, and other centralized bureaucracies, these non-VA staffing ratios did not emerge through a formal decision process on appropriate staffing. Rather, they reflect the day-to-day decision making of organizations facing various patient demands, budget and supply constraints, and much uncertainty about how to match resources to needs.

These difficulties notwithstanding, the committee believes that useful external norms can be developed. A necessary (though not sufficient) condition is that physician staffing ratios be "conditional" constructs, computed as a function of case mix and acuity, the availability of nonphysician personnel, and other factors affecting total requirements. Such ratios could be used to generate implied physician staffing at VAMCs, conditional on these factors.

The intended result would be that external norm criteria could be applied at the level of detail and specificity already characterizing the expert judgment staffing exercises and the EBPSM.

To accomplish this, a detailed examination of physician staffing levels in relationship to workload and other factors affecting physician productivity would need to be undertaken at each non-VA facility selected for analysis. The committee recommends that the VA pursue these more detailed external norm analyses. Such norms would represent a valuable supplement to the staffing information derived from the EBPSM and the SADI.

The primary purpose of the study has been to develop a physician staffing methodology, not implement it. Consequently, there are inherent limitations in the committee's ability to address the question, by specialty and program area, of whether current physician staffing in the VA is adequate overall.

Although the estimated empirically based models were used to derive physician requirements for all VAMCs (see chapter 4), such was not the case here for the expert judgment models. Both the SADI and the final versions of the DSE were applied only to the three (for psychiatry, four) VAMCs chosen as test sites for developing and refining these approaches (see chapter 5). Only for these facilities are there, via the panel analyses, estimates of physician requirements by all proposed empirically based and expert judgment approaches.

Hence, only for these test sites did the panels make quantitative assessments of whether VA physician staffing is adequate. (See the chapter appendix for a summary of each panel's estimates of the facilities' physician requirements, by approach, relative to the status quo reflected in the existing FY 1989 FTEE count.)

Without exception, the panels declined to render a quantitative assessment about whether the VA system was adequately staffed with physicians. Most panels did reach qualitative conclusions about staffing adequacy, however, based on the test site analyses and the general observations of individual panel members—both VA and non-VA—with years of experience working in VAMCs.

The committee's own conclusions are as follows:

• Relying solely on analyses performed in this study, it is not possible to reach sound quantitatively based conclusions on whether current VA physician staffing levels are adequate in the aggregate. (Though an important issue, it is not one the committee was asked to address.)

  The proposed physician requirements methodology can, and should, be used to estimate physician staffing deficits (or surpluses) by specialty and program area. These analyses should be performed at the facility level. By aggregating the results across VAMCs, the decision maker can estimate staffing deficits and surpluses for any desired grouping of facilities or for the system as a whole.

• But the approach selected for determining physician FTEE for patient care, resident education, administration, and leaves does bear some logical connection to the qualitative judgment about whether staffing is adequate.

To adopt an empirically based model—with its reliance on workload and FTEE data from the current system—for a given specialty or program area at a given point in time is consistent with the following qualitative judgment: Although individual VAMCs may have too many or too few of these physicians relative to VA systemwide productivity norms, the specialty or program is in the aggregate neither significantly understaffed nor overstaffed at that point in time.

This follows because the IPF model, by construction, serves to reallocate physician FTEE among VAMCs so as to leave unchanged the systemwide total. If the PF model is applied systemwide, this "zero-sum game" result is not guaranteed, but it is unlikely that the FTEE grand total will change significantly (see chapter 4).

The "point in time" phrase is inserted above because the conclusion might apply to some specialty or program now, but not five years from now, if workload expands faster than the physician resources to meet it or if other factors change.

Adopting either of the expert judgment approaches for a specialty or program area at a point in time is logically compatible with either of two conclusions:

1. Although some VAMCs may have too many or too few physicians, the VA system as a whole is inappropriately staffed at that point in time. Hence, the SADI or the DSE becomes the means to help move the system away from the status quo; or

2. The empirically based models are either conceptually inadequate or estimated with flawed data, so that expert judgment approaches are preferred on technical grounds.

• A major difficulty in drawing valid inferences about VA staffing adequacy is the absence of data relating physician FTEE (in any specialty or program) to measures of patient access and quality of care. Recent VA efforts to develop quality indices are noted in chapter 7. Also advocated there are statistical studies to investigate the linkages between physician staffing levels and indices of quality, as well as optimization models for deriving staffing levels that meet or exceed minimum quality standards.

  Until these linkages can be analyzed, inferences about the relationship between physician staffing intensity and patient outcomes will have to be derived by expert judgment, informed by the relevant available data.

• A close reading of the panels' final reports (see Volume II, Supplementary Papers) and of their meeting transcripts (unpublished) reveals a recurring theme, enunciated in qualitative terms: In most specialties and program areas, the VA currently has too few physicians in aggregate; in no case does it have too many.

The committee recognizes that each panel's conclusions reflect its own professional and specialty-oriented perspectives, its judgment about the staffing currently in the VA, and its beliefs about staffing requirements for the VA of the future. In keeping with this report's focus on methodology rather than the advocacy of specific staffing levels, the committee acknowledges the panels' views, but takes no formal position on their specific conclusions about the adequacy of current staffing. But these panel conclusions, emerging after months of careful deliberation by the panels, bear sufficient policy significance to warrant immediate investigation by the VA.

The proposed physician requirements methodology provides the means to do this. Specifically, the following should be undertaken:

After the SADI has been further tested and refined (see chapter 5), the Reconciliation Strategy should be applied across the system to determine which specialties or programs in which VAMCs are significantly understaffed. At a selected sample of these, the VA decision maker should provide the additional resources to bring physician staffing up to the recommended target levels (or intermediate target levels, as the local situation dictates).

The effect of improved physician staffing on indicators of access and quality over time should then be formally evaluated. In this way, the VA decision

maker would be moving quickly, selectively, and strategically in response to apparent resource deficiencies—while setting in motion analyses to determine whether increased physician staffing leads, in fact, to better outcomes.

In this hypothetical analysis, physician FTEE requirements are calculated through the Reconciliation Strategy, as summarized in Equation 6.1.

The focus is on one specialty, labeled s, at VAMC i. Four different physician FTEE totals are calculated: current staffing in s, as derived largely (though not entirely) from the facility's CDR, and three variants of the Reconciliation Strategy. For simplicity only, the projected workload relevant to s is assumed to be the same in all years.

In the specialty s at VAMC i, there are 20 staff physicians in all, 10 full time and 10 part time. They generate a total of 15.8 staff physician FTEE, distributed as follows in the CDR:

Additional survey data at i indicate 0.5 Contract FTEE for s and an estimated 0.6 FTEE from non-VA consulting physicians. Thus, total current physician staffing for specialty s is 15.8 + 0.5 + 0.6 = 16.9 FTEE.

Note that the 15.8 (and thus the 16.9) total incorporates implicitly all physician FTEE in specialty s associated with the following: administrative

duties (by service chief and others), allowance for leaves of absence of all types, and additional coverage for nights and weekends. For these latter categories, there is no separate FTEE breakout in the CDR.

Equation 6.1 establishes the framework for calculating physician requirements under the Reconciliation Strategy. Two principal elements of that equation are the Empirically Driven Baseline and the Modifier for the X component of physician FTEE—that is, X₁ and b(X₂-X₁), respectively.

In what follows, total physician requirements for specialty s at VAMC i will first be derived assuming the IPF is the centerpiece for determining X₁. Then total requirements for s will be derived with the SADI as the centerpiece for determining X₂. At that point, these calculations will be analyzed from the perspective of Equation 6.1, which allows the VA decision maker to derive (if desired) a weighted-average calculation of physician requirements that balances the strengths and weaknesses of the individual empirically based and expert judgment approaches.

Considered first will be the computation of X₁ and the additional FTEE required for research and for continuing education in specialty s. The sum of these three FTEE components constitutes an estimation of total physician requirements that is thus oriented around the Empirically Driven Baseline.

The FTEE subcomponents included in the dependent variable of the IPF encompass staff physician direct care and related administrative activities on the impatient, ambulatory, and long-term care PCAs; education and training/instructional costs (primarily for residents) by staff physicians; other miscellaneous activities by staff physicians (but here excluding FTEE under education and training/administration); and contract physician services.

Suppose that when the IPF estimated for specialty s is applied to VAMC i, the resulting predicted FTEE is 15.5. To complete this empirically based determination of X₁, the estimated FTEE are added for its subcomponents not reflected in the IPF. Here, the remaining subcomponents are education and

training/administration (recorded currently in the CDR as 0.4 FTEE for s), and non-VA consulting physicians (whose estimated FTEE is 0.6). When these are added to the IPF result, the total FTEE for the Baseline is X₁ = (15.5 + 0.4 + 0.6) = 16.5.

Recall that FTEE for administration (except as noted), leaves of absence, and night and weekend coverage are already reflected implicitly in the IPF's dependent variable; no further allowance is necessary.

Presently, 1.5 FTEE are allocated to research. By virtue of the committee recommendation that, in the short term, research FTEE be regarded as a pass-through, 1.5 FTEE will be assigned here. If this is regarded as an empirically driven choice, then R_l = 1.5 and c = 0 in Equation 6.1.

This implies that total FTEE to this point, namely (X₁ + R₁), is 18.0.

Suppose the VA decision maker concurs that FTEE for continuing education should be built into the physician requirement calculations at a rate of 80 hours/year per full-time physician. As noted earlier, this is equivalent to earmarking about 4 percent of total FTEE for this purpose.

If this is regarded as an expert judgment choice, then d = 1 in Equation 6.1. However, the implied value for C₂ is not immediately inferable but must be computed as a function of the FTEE estimated for X₁ and for research, as well as the 4 percent factor.

Given the choices made thus far, it can be shown that to expand the present FTEE total, namely (X₁ + R₂), to a new total reflecting the desired percentage of continuing education time overall, the computation is as follows:

This serves to inflate (X₁ + R₁) by just enough that 4 percent of the Total FTEE can indeed be assigned to continuing education while the original FTEE allocations to X₁ and R₁ remain unchanged.

Solving the Total FTEE equation for the absolute level of FTEE assigned to continuing education, one gets

Inserting the value computed for (X₁ + R₁) into the Total FTEE equation yields a value for (X₁ + R₁ + C₂) of 18.8 (after rounding), so that C₂ = 0.8 FTEE.

In sum, these calculations oriented around the Empirically Driven Baseline lead to total requirements in specialty s at VAMC i is 18.8 FTEE.

The components of Equation 6.1 will again be considered in turn.

Suppose that by applying the SADI constructed for specialty s to VAMC i, the FTEE required for direct care, resident education, and administration on the inpatient, ambulatory, and long-term care PCAs is calculated to be 18.5. From the SADI, 0.5 FTEE from specialty s is estimated for resident education in the classroom (not PCAs) and also 1.5 FTEE for administration by the service chief and others. Thus regarding the subcomponents of X₂, only leaves of absence remains to be analyzed. Under the SADI (or the DSE) expert judgment approach, there are conceptual advantages to deriving the FTEE equivalent for leaves at a subsequent stage in the calculation process, as seen shortly.

Hence, at this stage in the process, total FTEE for this element of the Modifier may be expressed as X₂ = (18.5 + 0.5 + 1.5 + Leaves ₂) = (20.5 + Leaves₂), where Leaves₂ is the FTEE requirement for leaves of absence.

Note that by virtue of the way physician task times are elicited within the SADI, there is no need to incorporate additional FTEE for contract or non-VA consulting physicians; that is, the SADI is designed to estimate total physician time requirements, irrespective of the mix of staff, contract, and non-VA consulting physicians.

If it is assumed that specialty s is not significantly involved in outpatient emergency and admitting & screening activities, one would (by virtue of a committee recommendation in chapter 6) add no additional FTEE for night and weekend coverage. Hence, X₂ remains at (20.5 + Leaves₂).

Presently, 1.5 FTEE are allocated to research. By virtue of the committee recommendation that, in the short term, research FTEE be regarded as a pass

through, 1.5 FTEE will be assigned here. Assuming again this is regarded as an empirically based determination, R₁ = 1.5.

This implies that total FTEE, to this point, is (X₂ + R₁) = (20.5 + Leaves₂ + 1.5) = (22.0 + Leaves₂).

As before, assume the VA decision maker agrees that FTEE for continuing education should be built into the calculations at a rate of 80 hours/year per full-time physician—the equivalent of earmarking about 4 percent of total FTEE for this purpose.

Again, the implied value of C₂ is not immediately inferable here, but must be derived as a joint function of several factors: X₂, R₁ , and the 4 percent factor. Note, however, that X₂ = (20.5 + Leaves ₂), and that the value of Leaves₂ is yet to be determined; hence, before one can derive the implied value of C₂, the calculation of Leaves₂ must be addressed.

Suppose the VA decision maker adopts the committee's recommendation that (in computing X₂) the FTEE allowance for leaves of all types be derived from the permissible amounts of annual leave available to full-time and part-time staff physicians. Recall that the annual leave ceiling for a full-time VA physician is the time equivalent of 0.12 FTEE, whereas for a part-time physician, the ceiling amounts to 0.08 FTEE. As before, let f be the fraction of full-time physician FTEE in total physician FTEE.

Now, the value of Leaves₂ (like C₂) is not immediately inferable here, but must be derived as a joint function of several factors: R₁, C₂, the other subcomponents of X₂, as well as the 8 percent and 12 percent factors and the fraction f. Consequently, Leaves₂ and C₂ depend, in part, on each other and must be jointly calculated in the final step leading to total physician requirements under this X₂-oriented approach. The formula for carrying out this final step is as follows:

where 0.04 is the desired fraction of FTEE for continuing education in total FTEE, and 0.12 and 0.08 are the desired fractions of FTEE for leaves of absence in total FTEE for full-time and part-time VA physicians, respectively.₂

To estimate f, recall that specialty s now has 10 full-time physicians and a total staff physician FTEE of 15.8. If one assumes that f remains relatively unchanged as staffing moves from the status quo level to that prescribed by this Reconciliation Strategy variant, then a reasonable estimate of this parameter is 10/15.8 = 0.63.

Thus, Total FTEE = 0.63(22.0)/(0.84) + 0.37(22.0)/(0.88) = 25.8, where 22.0 = (20.5 + 1.5) = [(X₂-Leaves₂) + R₁].

By construction, 4 percent of this total—that is, 25.8 × 0.04 = 1.0 FTEE—is to be allocated to continuing education. Similarly, [0.67(0.12) + 0.37(0.08)] × 100 percent = 11 percent of the total is to be allocated to leaves of absence; that is, 25.8 × 0.11 = 2.8 FTEE are for this purpose. [This implies that (25.8-1.0-2.8) = 22.0 FTEE remain for the subcomponents of X₂ excluding leaves of absence, plus research—and this is precisely the intended result.] It follows that X₂ = [(X₂-Leaves ₂) + Leaves₂] = 20.5 + 2.8 = 23.3 FTEE.

Thus, total FTEE for X₂ has been calculated in a way that simultaneously satisfies the following stipulations: (1) total FTEE for all subcomponents of X₂ except leaves of absence is based on the SADI; (2) the leaves subcomponent is based on the current VA rules regarding annual leave; (3) research FTEE is set at the current CDR-recorded level; and (4) continuing education FTEE is pegged at a level consistent with 4 percent of the total being devoted to this purpose.

When all FTEE-component variables (and weighting parameters) determined to this point are substituted into Equation 6.1, one obtains

²As a small concession to simplicity, this equation ignores the fact that X₂ will typically include some non-VA physician FTEE, for example, for C&A and WOC support and contract services. Strictly speaking, the leave adjustment should be performed only for VA staff physicians. The precise statement of total FTEE under this variant requires a somewhat more complicated formula:

where is the VA staff physician component of X₂; thus, (X₂-), the non-VA-physician component of X₂, is not adjusted upward to allow for leave-induced productivity losses.

where R₂, representing an expert judgment-based estimate of research FTEE requirements, was not formally considered (by assumption); C₁ , representing an empirically driven estimate of FTEE required for continuing education, was not formally considered (by assumption); and C₂, representing an expert judgment-based assessment of FTEE for continuing education, was defined here to be 4 percent of Total FTEE. Thus, C₂ is jointly determined with Total FTEE. When that total is oriented around X₁, C₂ is found to be 0.8 FTEE; when the total is oriented around X₂, the calculated value of C₂ is 1.0 FTEE.

Hence, the linchpin decision in executing the Reconciliation Strategy (in this example and in most real applications) is determining the appropriate value for the parameter b. Basically, the VA decision maker has three alternatives:

1. Set b = 0 (and thus select Empirically Driven Baseline),

2. Set b = 1 (and thus select the expert judgment element of the Modifier), or

3. Set b between 0 and 1 (and thus select a weighted average of these two that presumably balances the strengths and weaknesses of each).

Suppose that after considering a number of factors (e.g., pertinent local data omitted from either the IPF or the SADI), the VA decision maker sets b = 0.25. Then X = [16.5 + 0.25(23.3-16.5)] = 18.2. Of course, R = 1.5. To determine Total FTEE in a way that properly incorporates the required FTEE for continuing education, one can adapt the formula used earlier:

To summarize, under this particular weighted-avarage variant of the Reconciliation Strategy, X = 18.2, R = 1.5, C = 0.8, and Total FTEE = 20.5. By comparison, when b = 0, Total FTEE = 18.8; and when b = 1, Total FTEE = 25.8.

If local circumstances at VAMC i argue that this specialty s staffing target of 20.5 FTEE should be phased in, the VA decision maker would initially increase staffing to an intermediate target level that lies between the status quo of 16.9 and 20.5.

American Medical Association, Office of Physician Credentials and Qualifications . 1986. Information Booklet on the Physician Recognition Award. Chicago, Illinois.

The following appendix comprises the concluding sections of the reports of the six specialty and two clinical program panels, whose full reports are contained in Volume II, Supplementary Papers. Each panel's conclusions are presented here as a distinct entity for ease of reproduction and use.

For determining VA physician requirements in internal medicine, the panel endorses a variant of the study committee's Reconciliation Strategy that puts primary weight on ''data-driven'' approaches to calculating FTEE. Regarding the FTEE components of the Reconciliation Strategy, the panel recommends the following:

Internist FTEE for patient care should be derived from the PF version of the EBPSM. The panel feels that the PF model is conceptually superior to the IPF because it is specific to the PCA, not just to the facility. Therefore, it allows total physician requirements for patient care to be derived as the sum of FTEE required on all PCAs. For VAMCs I, II, and III, the PF model yielded FTEE levels in better accord with the panel's own judgment about appropriate staffing than did the IPF model. Since the PF focuses entirely on patient care, additional facility-specific data would be required to capture (1) FTEE devoted to resident education and miscellaneous activities and (2) other FTEE not in the CDR and, hence, not in the PF. Included in the latter are FTEE representing contract physicians and C&A and WOC physicians.

The panel believes that expert judgment approaches for determining physician requirements are also valid, but, compared with statistically based approaches, they are relatively expensive and cumbersome to operate. Because the panel concludes that the PF model represents a satisfactory approach for determining internal medicine requirements—given current VA staffing arrangements—it sees no need to utilize either the SADI or the DSE as primary tools for calculating FTEE for medicine.

The panel recognizes that other specialties may find it useful to apply some form of modifier (perhaps multiplier) to the EBPSM in order to derive FTEE estimates that would properly account for historical patterns of understaffing or changes in the technology of treatment. In a given facility, this may also be required for internal medicine. The proposed Reconciliation Strategy provides a useful framework for deploying such multipliers.

The panel had difficulty ascertaining the proper allocation for research. Many facilities are research hospitals whereas others perform no significant investigations. The issue becomes even more complicated since the goal of increased research may exist at a hospital before a full research staff can be

recruited. The amount of FTEE assigned to research in the CDR over several years may serve as an initial approximation. However, the panel believes that independent support of these estimates is necessary. For example, each facility should provide a list of the staff physicians who have grant support from the National Institutes of Health or other major funding agencies (e.g., American Heart Association) or a merit award from the VA. In a given VA medicine service, if 10 FTEE are listed for research in the CDR, but only three investigators have independent grant support, then the amount of FTEE assumed for research in the execution of the Reconciliation Strategy should not be 10 but a much smaller number. (It is presumed that serious investigators will have grant support.) Other data such as dollar funding levels or published papers from the facility could be used but are probably more difficult to evaluate than the independent funding criterion.

It is important that a VAMC demonstrating strength in research be allowed to have sufficient physician FTEE to maintain (or improve) its program over time. Only in this way will the research base of the VA system be maintained.

No fixed standard for continuing education exists in major medical centers in the VA system or outside. Much continuing education takes place in internal teaching functions such as grand rounds. A reasonable figure for meetings outside the medical center would be 10 working days per year. This would allow attendance at two major medical meetings every 12 months.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should follow established VA rules.

Assuming an adequate availability of residents, none is required.

Assuming the VAMC is adequately staffed with VA physicians, there is no need for additional C&A and WOC FTEE.

There are at least three significant problems in applying non-VA staffing standards to determine the appropriate number of VA physicians in internal medicine. First, it is exceedingly difficult to obtain comparable FTEE counts from most private-sector facilities. Much of the patient care in community and university hospitals is provided by attending physicians or faculty who admit patients and spend variable amounts of (generally unrecorded) time treating them. Second, there are differences in the economic incentives facing VA and most non-VA physicians. A growing percentage of non-VA physicians are under increasing pressure, from hospitals as well as third-party payers, to control costs; this may affect practice styles and the pattern of care. Third, it is difficult to identify facilities with patient populations comparable to the VA's.

Hence, the panel found the external norms analysis interesting but not very useful for determining VA requirements in internal medicine.

With a sample of but three VAMCs examined in detail, the panel feels that it is not possible to produce a defensible quantitative assessment of whether the VA is understaffed or overstaffed in internal medicine. However, the panel's endorsement of an EBPSM, with its concomitant reliance on input-output data from the current system, followed from the observation that expert judgment estimates, although in general slightly higher than numbers derived from the empirical models, were in actuality quite close. Although individual VAMCs may have too many or too few internists relative to systemwide productivity norms, internal medicine in the aggregate does not appear to be significantly understaffed at present. However, the panel emphasizes that this should not be regarded as a "permanent" conclusion, but rather one to be reevaluated periodically.

A reasonable approach to investigating in more depth whether physician staffing in medicine is appropriate would be to apply either the SADI or the DSE to all (or a representative sample) of VAMCs and compare the resulting FTEE levels with those obtained from the PF model and with actual staffing at these facilities. That is, the analyses performed on VAMCs I, II, and III could be extended to a number of VAMCs. Then, one would have considerably more

information for evaluating the appropriateness of both current staffing and the PF model as a tool for helping establish desirable FTEE levels.

In implementing any staffing model, the VA should establish an appeals mechanism that allows a VAMC to question what it believes, on objective grounds, to be an unreasonable staffing recommendation. There may be evidence that the facility's reported data are in error or are no longer relevant. Factors relevant to physician requirements at the facility may have been omitted entirely from the model (since no true model will include all factors that bear on staffing at every VA).

One natural step in the appeals process would be to apply either the DSE or a rather detailed version of the SADI to the VAMC in question. This result could be compared with the facility's current staffing and the level derived from the PF. With this information available, VA decision makers at the facility and Central Office would have a firmer basis on which to reach a final judgment.

In this regard, the panel urges the VA to continue efforts to improve the accuracy of the FTEE data in the Cost Distribution Report.

For determining VA physician requirements in internal medicine, the medicine panel endorses a variant of the Reconciliation Strategy that relies upon the PF for deriving FTEE for patient care, resident education, and administration. In general, the panel favors data-driven approaches to determining physician requirements in medicine.

The panel's estimate 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. 1. These results are of interest in their own right and serve also to establish the FTEE boundaries within which the panel's Reconciliation Strategy-derived estimates would likely fall. In particular, the PF-based estimates in the table should closely approximate what would emerge from applying this panel's Reconciliation Strategy recommendations to VAMCs I, II, and III.

[Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

For determining VA physician requirements in both surgery and anesthesiology, the panel recommends particular variants of the Reconciliation Strategy (the "disaggregated weighted-average" approach proposed by the study committee). Regarding the FTEE components of the Reconciliation Strategy, the panel proposes the following:

For surgery, the panel concludes that both the DSE and the SADI are viable approaches for determining FTEE for these activities. Purely statistical approaches to staffing, although conceptually well founded, are problematic at present because of flaws in the VA data used in their estimation. On the basis of its experience with both expert judgment methodologies, the panel regards the DSE as closer to a "gold standard" approach to staffing, yet recognizes that it would be highly cumbersome to implement regularly across the VA system. Hence, the panel believes that adopting a suitably refined version of the SADI instrument would be the more appropriate option; these refinements should include, in particular, a more detailed specification of case acuity, on the wards as well as in the operating room.

The panel has several concerns about the empirically based models' reliance on data from the VA CDR. If the PF or the IPF were to be the primary tool for determining physician requirements, then greater attention must be paid to improving the overall accuracy of the CDR data. In surgery, it may be particularly important for the EBPSM to distinguish between full-time and part-time FTEE, since a substantial amount of the VA's surgery is performed by physicians whose major appointments are elsewhere. Eight of these surgeons each working one-eighth time in the VA are not likely to be the productivity equivalent of one full-time VA surgeon. A similar issue arises for anesthesiology. Another issue affecting both surgery and anesthesiology is that some VAMCs have no distinct cost center for anesthesiology (cost center 212); in those facilities, anesthesiologist FTEE are counted in the surgery cost center (202). In such cases, the number of surgeons would be overestimated and anesthesiologists underestimated.

In sum, for determining surgeon FTEE for patient care, resident education, and administration, the panel endorses a weighted-average strategy with all of the weight placed on a SADI-based approach. [In the terminology of the Reconciliation Strategy, this is equivalent to setting b = 1; see Equation 6.1.]

For anesthesiology, the panel recommends a variant of the Reconciliation Strategy that allows (but does not require) the VA decision maker to place due weight on both expert judgment and empirically based approaches in calculating

physician requirements. As described in chapter 6, the analytical vehicle for accomplishing this is a particular specification of the Reconciliation Strategy in which the parameter b is allowed to vary between 0 and 1.

To arrive at compromise positions about the appropriate FTEE levels for the VA medical centers studied here in depth, the panel's two anesthesiologists engaged in an exercise to derive a "consensus" value of b for each facility. For VAMCs I, II, and III, the means (midpoints) of the anesthesiologists' b values were, respectively, 0.43, 0.49, and 0.38.

The panel emphasizes that these particular weightings are specific to these particular facilities; hence, they are a reflection of, and serve to articulate, the anesthesiologists' professional judgment about appropriate physician staffing for these facilities. If other VAMCs had been examined, different b values would likely have emerged. In general, the Reconciliation Strategy should be executed on a facility-specific basis, so that relevant local data and circumstances can be factored into the staffing decision process. In this way, the parameter b becomes an appropriate reflection (or articulator) of the decision process, not the mechanical driver of that process.

The panel feels strongly that FTEE allocations for research should be related to measurable indicators of research productivity and excellence. The amount of VA and non-VA research support is considered the single most important indicator. Quite clearly, not all surgery and anesthesiology services in the VA merit the same level of research FTEE.

There ought to be some minimal level of continuing education built into the FTEE requirements of all VAMCs. A figure of 10 days per year was discussed, but there was no consensus about the exact amount of time to be devoted to continuing education. There was, however, a clear consensus that continuing education is important for quality assurance and should be specifically recognized in calculating surgeon and anesthesiologist requirements.

The percentage of time allocated to various types of leave should be calculated in a way consistent with the VA's own policies and practices. The

panel believes that these analyses would suggest that about 12 percent of total FTEE is a reasonable allocation.

Assuming an adequate availability of residents, none is required.

The use of C&A and WOC physicians enhances the quality of clinical and educational activities in the VAMC. The panel also notes that in affiliated VAMCs, C&A and WOC surgeons can make important contributions to handling some portions of patient workload and resident training. However, given the increasing cost pressures facing the academic affiliates, the panel urges that when the VA computes surgeon requirements, it does not make unwarranted assumptions about the availability of C&As and WOCs. Rather, the fraction of total surgeon FTEE requirements to be filled by VA staff physicians should be determined only after careful consideration of the local availability of C&A and WOC surgeons.

Developing non-VA physician staffing standards to which the VA's own staffing could be validly compared proved difficult for several reasons.

First, most non-VA facilities do not measure physician time in terms of an FREE. There is no need for these hospitals to do this since surgeons, anesthesiologists, and other physicians are not paid from a central budget but participate in clinical and educational activities as "attending" physicians with widely varying time commitments.

Second, a portion of the surgery workload at many non-VA institutions is comparable to the workload found in VAMCs. But given current data systems in the private sector, it is exceedingly hard to determine how much physician time is devoted to caring for the VA-comparable portion of total workload.

Third, since few private institutions have established explicit staffing standards, and there are no nationally recognized standards, one can question how much policy significance should be given to observed staffing ratios.

It is evident from Tables 6A.2a and 6A.2b that the panel does not regard surgery and anesthesiology staffing to be adequate (in FY 1989) at the three VAMCs studied in depth. However, the panel feels that it is premature to draw general conclusions about the adequacy of staffing in these specialties across the VA. If the SADI or the DSE could be applied to facilities across the board, the panel is confident that the question of staffing adequacy could be addressed quantitatively.

First, all FTEE estimates derived from the SADI and the DSE assumed a 40-hour work week. In reality, surgeons and anesthesiologists work much more than this—perhaps closer to a 55-hour week. If some such higher (and more realistic) hours-per-week assumption were to be used, the derived FTEE levels presented in the panel's report would be reduced accordingly. The way in which hours are converted into FTEE is an important issue that the study committee may want to review.

Second, though the panel kept to its charge of examining the physician FTEE (rather than physician expenditures) required to meet workload, it emphasizes that one budgetary complication cannot be ignored. In most areas, the going market rate for one FTEE surgeon or anesthesiologist is considerably more than the VA's top salary level. Thus, a VA requiring X anesthesiologist FTEE would need to budget for some greater number (X + Y) to have sufficient funds to purchase X. Failing that, the VA must work out some form of reciprocal agreement with its affiliated medical center to augment its anesthesiology staffing. But these affiliates are under increasing pressure to cut costs, and they may become increasingly resistant to such sharing arrangements.

For establishing VA staffing standards in surgery and anesthesiology, the panel endorses the study committee's Reconciliation Strategy, with the components of FTEE specified as indicated above.

The panel concludes with a summary (Tables 6A.2a and 6A.2b) of its estimates of physician requirements for three actual VAMCs, based on applications of the empirically based and expert judgment approaches discussed above.

[Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

For determining VA physician requirements in psychiatry, the panel endorses a variant of the Reconciliation Strategy that offers the flexibility to use expert judgment approaches as a corrective to statistical staffing models. Regarding the FTEE components of the Reconciliation Strategy, the panel recommends the following:

For these activities, the VAMC's target level of FTEE should be determined through an expert judgment process, not by one of the proposed empirically based models. Although the panel admires the rigor of the statistical models, at best they can indicate only how the current aggregate level of psychiatry FTEE can be better distributed across VAMCs. It appears unlikely that these models, alone, can address an issue the panel feels is paramount: The VA, as a whole, is now understaffed in psychiatry. (The panel acknowledges that if these staffing deficiencies are reduced, then eliminated, it may well become appropriate to consider deriving psychiatry staffing requirements largely from empirically based models.)

Given projected workload and other factors, what is the appropriate target level of psychiatry FTEE required for patient care, resident education, and administration? To address this question, the panel recommends a form of the Reconciliation Strategy whose expert judgment component is built around the SADI. Although the DSE is an excellent vehicle for examining staffing at an individual VAMC in depth, to apply this instrument across the system would be very labor intensive—possibly requiring a ''permanent'' expert panel to interpret and update the data. The SADI methodology, on the other hand, could be applied comparatively rapidly to compute psychiatry staffing levels for all VAMCs.

The current SADI instrument, although promising, is an experimental construct. The VA should apply it across the system, revise it on the basis of what is learned, and then periodically reevaluate and update it. This would require some form of expert panel, but the overall manpower commitment would be less than for a DSE-Based approach.

When the panel applied the SADI (and also the DSE) at four selected VAMCs, all were found to be understaffed. One facility (VAMC III) was seriously short of psychiatrists by any standard.

Reflecting on these results, the panel feels that it is not feasible to immediately achieve the several-fold increase in psychiatry staffing that is derived from this initial version of the SADI for facilities such as VAMC III. Rather, the panel endorses a variant of the Reconciliation Strategy in which

psychiatrist FTEE at a VAMC is incremented initially by some appropriately chosen fraction of the total difference between the SADI-derived level and the current level.

To arrive at these psychiatry staffing targets, the panel experimented successfully with, and recommends to the VA, a weighted-average version of the Reconciliation Strategy. The IPF and the SADI served as the core approaches for establishing the FTEE boundaries of staffing targets for patient care, resident education, and administration. In the current terminology of the Reconciliation Strategy, a value of 0.35 for the weighting parameter b (see Equation 6.1) seemed reasonable to the panel—given the four VAMCs evaluated.

The panel emphasizes that had a different group of facilities been analyzed, the ratio might have been different. Indeed, there is a strong case that the parameter b should be determined on a facility-specific basis, in response to relevant information about current staffing at the VAMC and other factors.

The panel urges the VA to refine the SADI further, then perform these calculations across the board to derive psychiatry staffing targets for all VAMCs in the system. The most seriously understaffed facilities should have top priority in acquiring the resources necessary to boost staffing up to computed target levels, and the implications for patient care should be evaluated over time. Average length of stay, treatment outcomes, rates of rehospitalization, and other indicators of the quality and effectiveness of care should be monitored at these selected facilities.

If these indicators improve significantly over time, subsequent iterations of the Reconciliation Strategy should indicate, in response, that additional psychiatrists are appropriate. Thus, what the panel anticipates, if the Reconciliation Strategy is implemented properly, is a type of "transition" or "phasing in" policy, in which psychiatrist FTEE are initially incremented at a number of VAMCs, then further increased over time as the supporting data emerge.

It is important that the initially derived staffing targets be sufficiently different from the status quo FTEE levels that the anticipated resulting changes in the quality and effectiveness of care are observable and measurable.

The panel has serious concerns about adopting an empirically based approach for determining research FTEE in psychiatry in the absence of accompanying policies that recognize an important equity point. Psychiatrists at many VAMCs have been so pressed to handle patient care demands that little time has been left for research. Current FTEE allocations to research in the CDR are smaller than would be the case in a less strained system. To compensate for this inequity, the VA should consider providing "seed money" to stimulate research activities of VA physicians in specialties, such as

psychiatry, where the opportunity to launch promising projects has been limited. The panel feels that research improves both physician recruitment and retention, and the quality of care. It recommends that the amount of FTEE allocated to research be a conscious VA policy decision not tied to the status quo. This allocation should be determined on the basis of scholarly promise, but should reflect a genuine commitment to equal opportunity.

Allocations for research derived from existing data will only perpetuate existing inequities in psychiatric research.

Physician FTEE for continuing education should be based on what the individual VAMC has deemed to be an appropriate level. The most straightforward indicator of this is the amount of FTEE allocated to continuing education on the facility's CDR in the previous fiscal year.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be based on existing VA policies.

There is a need for continuous backup coverage (on-call coverage for nights and weekends) by staff psychiatrists. The extent to which the backup coverage amounts to actual hours put in on the wards will be a function of several factors including the allocation of resident staffing, case mix, and case acuity. The panel therefore supports a policy calling for additional (purchased) psychiatrist FTEE for nights and weekends. This additional staffing cannot be calculated globally through a formula, but must be determined on a facility-by-facilitybasis.

Assuming the VAMC is adequately staffed with VA physicians, there is no need for C&A and WOC FTEE to meet basic patient care demands. But these non-VA physicians can enhance the overall quality of care at the VAMC and play a valuable role in resident education and continuing education for the staff.

Efforts to uncover non-VA staffing criteria, or norms, that could be used to evaluate psychiatry staffing in the VA proved to be problematic.

As indicated in the panel's full report (see Volume II, Supplementary Papers), workload-to-psychiatrist FTEE ratios were computed from data derived from a variety of non-VA sources, including private psychiatric facilities, university hospitals, and public treatment facilities. In the end, the panel concluded that it is simply inappropriate, and potentially misleading, to apply simple ratios of this type to infer appropriate staffing at VAMCs. There are both methodological and philosophical problems with such comparisons.

Methodologically, there were two major difficulties in comparing staffing ratios across facilities. First, there was no control, or adjustment, for possible differences in patient severity; thus, a patient day or a patient visit was assumed to be a relatively homogeneous workload index. In fact, this may not be the case. Second, it was not possible to apply a standard definition of a psychiatrist FTEE, nor could the panel accurately split out a non-VA facility's FTEE into inpatient and outpatient components. (One can attempt to do this for VA psychiatrists via the CDR.) The net result is that the denominator in the staffing ratios could not be defined and computed uniformly.

Philosophically, a major caveat is that most of these non-VA ratios emerged not through some formal decision on optimal staffing, but rather as behavioral responses to patient demands in light of various incentives and constraints. For private psychiatric hospitals, in particular, there is a question about what factors influence physician staffing levels. In some, a concern for profits and the accompanying desire to control costs likely influence the observed ratios at these facilities. In others, many participating psychiatrists are community based and their FTEE are not well recorded (or counted at all) in the facility's personnel system; consequently, workload-to-psychiatrist ratios computed at such sites would tend to be inflated.

Future efforts to develop external staffing norms should focus largely on university hospitals and other selected facilities with a demonstrated concern for the quality of care. The analyses should be performed in detail, so that adjustments can be made for important differences between the non-VA sites and the VAMCs to which the norms would be applied.

For the four VAMCs studied in depth, psychiatry staffing was not adequate in FY 1989. In all four, the current FTEE level was significantly below the FTEE level derived using the SADI. At least two of the four (VAMCs III and IV) are severely understaffed.

The panel believes that the findings emerging from this small-sample study fairly reflect the state of psychiatry staffing in the VA, but it would be premature to draw conclusions about the overall extent of understaffing in each of the facilities across the system. If a version of the SADI (after further testing and development) were applied via the proposed Reconciliation Strategy to a broader sample of VAMCs, the overall situation could be assessed more precisely.

In determining physician staffing in psychiatry, the panel recommends a variant of the Reconciliation Strategy in which FTEE targets are formally established and evaluated, as indicated above.

A summary of the panel's estimates of physician requirements for four actual VAMCs is provided in Table 6A.3.

[Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

The panel endorses the study committee's Reconciliation Strategy (the "disaggregated weighted-average" approach) as a framework for computing physician requirements in neurology. Regarding the FTEE components of this strategy, the panel recommends the following:

Neurology FTEE for these activities should be calculated from an expert judgment-based staffing model, not from an empirically based model that relies on current VA staffing data. Both the SADI and the DSE are acceptable expert judgment models. Because the DSE provides a richer array of details about workload and other facility-specific factors, it is arguably closer to a "gold standard" methodology than the SADI. Yet, for determining VA neurologist FTEE over the long term, the panel favors the SADI. Because it is a generic rather than a facility-specific construct, it will be more economical to apply on a systemwide basis than the DSE. The SADI's task-time estimates can be periodically reevaluated and updated as new data become available. The neurology version of the SADI is ready for its initial systemwide application; this should proceed without delay.

Neither the PF nor the IPF version of the EBPSM is acceptable at present because the VA data used in their estimation is flawed in at least two significant respects.

First, these data (of necessity) reflect current input-output relationships, which are skewed because (in the panel's view) neurology is seriously understaffed in many VAMCs. That is, the current data reflect the status quo, and that is an inadequate basis for drawing policy conclusions about appropriate staffing in neurology.

Second, in more than half of all VAMCs there is no neurology service (though one or more neurologists at such a facility may perform consultation on other services). In these cases, the existing neurology FTEE may be attributed, completely or in part, to the medicine service; when this occurs, both the NEU_MD and the MED_MD variables in the PF and the IPF models will reflect some measurement error, which will lead to biased coefficient estimates in the EBPSM. In addition, the panel has concerns that the outpatient workload variable used in the present PF and IPF models (NEUCAPWWU) may also suffer from measurement error problems.

Between the two empirically based models, the IPF function is preferred. Even though neurologists consult on many types of VA services, the neurologist FTEE variable is statistically significant in only three of the 14 PCA-specific PF equations. Thus, deriving neurologist FTEE from these equations will almost

certainly underestimate total neurologist requirements for patient care at a given facility. Because the IPF properly acknowledges all recorded neurologist FTEE at a facility, regardless of the degree to which it appears to "produce" workload, this form of underestimation will not arise with the IPF. A second advantage of the IPF is that, because it is estimated at the facility level, it does not require neurologist FTEE allocated across PCAs or between patient care and resident education. Because FTEE allocations to PCAs and among activities are frequently made arbitrarily, it is preferable to avoid models, such as the PF, that require them.

An empirically based, rather than expert judgment-based, approach should be adopted for determining FTEE allowances for research. The most straightforward, reasonable procedure is to assign each neurology service (or consultant service) the amount of research FTEE allocated on the facility's CDR in the previous fiscal year. An alternative approach deserving investigation is to make these FTEE allowances dependent on quantitative measures of research productivity, such as grant funding levels. The greater the demonstrated research productivity of a neurology service, the higher should be its FTEE allocation to research, both in absolute terms and (typically) as a percentage of total FTEE.

Like the research allocation, physician FTEE for continuing education should be based on what the individual VAMC has deemed to be an appropriate level; the most straightforward indicator of this is the amount of FTEE allocated to continuing education on the facility's CDR in the previous fiscal year.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be based on existing VA policies.

Assuming an adequate availability of residents, none is required.

Assuming the VAMC is adequately staffed with VA physicians, there is no need for additional C&A and WOC FTEE.

The panel concludes that it is difficult to apply non-VA staffing standards to determine the appropriate number of neurologists for the VA. Across facilities there are substantial differences in what is meant by "patient workload" and "physician FTEE." In many institutions, neurology is still part of internal medicine. Staffing in private hospitals is frequently driven by concerns about profit margins, which may influence physician staffing intensity; this calls into question whether a desirable norm is being observed. University medical centers generally deliver high-quality care, but serve a patient population quite different from the VA's.

From Table 6A.4 it is evident that actual neurology staffing in FY 1989 at all three VAMCs examined in detail by the panel is below that recommended by any of the proposed approaches to staffing. These results are consistent with the conclusion that neurologist staffing in the VA may not be adequate at present. But because of the small sample size of facilities examined, it is not possible from these analyses to render a quantitative assessment of neurologist understaffing for the system.

Regardless of whether the VA adopts an empirically based or expert judgment-based approach (or some combination) to physician staffing, the models should distinguish sharply between VAMCs that have a full neurology service and those that offer only neurology consultation.

If the VA does adopt an empirically based approach, it is crucial that neurologist FTEE allocations in the CDR be made more accurate. As noted, this is especially important for the PF, wherein physician FTEE are allocated by function to various PCAs. In addition, the ambulatory workload variable used in the present models (NEUCAPWWU) must be refined so that it becomes a

better direct indicator of the work performed by the neurologist in the clinic setting.

For neurologist staffing, the panel recommends a variant of the Reconciliation Strategy in which the FTEE required for patient care, resident education, and administration would be determined through the SADI.

The panel's estimate 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.4.

[Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

As a framework for determining VA physician requirements in both rehabilitation medicine and spinal cord injury (SCI), the panel endorses a variant of the study committee's Reconciliation Strategy (the "disaggregated weighted-average" approach). With respect to the FTEE components of the strategy, the panel recommends:

For these activities, FTEE should be derived from an expert judgment model rather than the EBPSM. Both the SADI and the DSE represent acceptable expert judgment models, but the SADI is preferred because it will be easier and more efficient to apply across the system. Although application of the rehabilitation medicine SADI to VAMCs I, II, and III resulted generally in reasonable physician FTEE estimates, its acceptability and reasonableness should be assessed on a systemwide basis soon, and reevaluated periodically.

Neither the PF nor the IPF variant of the EBPSM is fully acceptable because the VA data used in their estimation have potential errors in two major areas.

First, these data (of necessity) reflect current input-output relationships, which are skewed because rehabilitation medicine is seriously understaffed in many VAMCs; thus the data reflect the status quo, clearly an inappropriate basis for estimating appropriate physician staffing for high-quality rehabilitation medicine and SCI patient care.

Second, in over half of all VAMCs there is no inpatient rehabilitation medicine service (RMS), though one or more physiatrists at such a facility could consult on other services. In these cases, there is a likelihood that the existing RMS FTEE will be attributed, completely or in part, to the medicine service. If this occurs, both the RMS_MD and the MED_MD variables in the PF and the IPF models will reflect measurement error. The panel believes that this could result in a substantial underestimation of physician requirements in rehabilitation medicine.

An empirically based, rather than expert judgment-based, approach should be adopted for determining FTEE allowances for research. One method is to assign each RMS and SCI service (or consultant service) the research FTEE allocated on the facility's CDR in the previous fiscal year. Another approach is

to base research FTEE on indicators of research productivity, such as the amount of grant funding. The panel prefers the latter approach.

Physician FTEE for continuing education should be based on the individual VAMC's recommended level; this can be easily determined as the amount of FTEE allocated to continuing education on the previous fiscal year's CDR.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be consistent with the VA's policies.

Assuming an adequate availability of residents, none is required.

In rehabilitation medicine, this category is primarily for education purposes.

The panel pursued this topic with both enthusiasm and some ambivalence; it now concludes that there is much difficulty in applying non-VA staffing standards to determine the appropriate number of rehabilitation medicine and SCI physicians for the VA. Staffing levels in private, freestanding hospitals are frequently influenced by the profit motive. In affiliated university hospitals, there are technically more complex procedures performed with a different group of patients; physiatrist FTEE in these settings is not measured comparably to the comprehensive approach taken by the VA. Furthermore, the education of residents and allied health workers is more intensive at university hospitals, necessitating a more intensive involvement of attending physicians in the training process. Some other organizations examined (e.g., Department of Defense) treat a substantially different patient mix than do VAMCs; hence, their patient populations present different management problems than those in most VA facilities.

From Table 6A.5 it is evident that actual rehabilitation medicine staffing in FY 1989 at two of the three VAMCs examined in detail is below that recommended by any of the models, except the PF; however, for VAMC III, only the DSE result is significantly greater than current RMS staffing, as reflected in the CDR. Because this is indeed a small sample, it would be premature to present a quantitative assessment of understaffing for the system.

Regardless of whether the VA adopts an empirically based or expert judgment-based approach (or some combination) to physician staffing, there would be much merit in developing models that distinguish sharply between VAMCs with a full RMS program, including a bed service, and those that offer only RMS consultation.

If the VA does adopt an empirically based approach, it is crucial that rehabilitation medicine physician FTEE allocations in the CDR represent more accurately how the physiatrists at a given VAMC spend their time.

For rehabilitation medicine and SCI physician staffing, the panel endorses the modified version of the Reconciliation Strategy described above. For patient care, resident education, and administration, the centerpiece of the staffing model would be the SADI.

The panel's estimates of physician requirements for three actual VAMCs are shown in Table 6A.5. The expert judgment estimates reflect the collective experience of the panel's VA and non-VA members.

[Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

As a framework for determining physician requirements in the specialties of laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology, the panel endorses the "disaggregated weighted-average" approach to the Reconciliation Strategy (see Equation 6.1 and the accompanying text). Regarding the components of the strategy, the panel recommends the following:

For these activities, FTEE should be derived from expert judgment methodologies. Although both the Staffing Algorithm Development Instrument (SADI) and the Detailed Staffing Exercise (DSE) are acceptable expert judgment approaches, the SADI is preferred. The focus of the SADI is on the time required by physicians to perform specific tasks and functions, making it suitable both for technologically based specialties, like laboratory medicine, and specialties that also have a strong component of physician-patient interaction, such as nuclear medicine. The panel has made a first-cut effort to estimate these SADI task times.

On the basis of these results, the panel concludes that the SADI should be applied experimentally at a representative sample of VA medical centers to derive first-cut estimates of physician requirements in the four specialties. It would be possible to apply the DSE within the same representative sample, but the administrative burden would be considerably greater; in the judgment of the panel, that entire process would be inefficient since distinct DSE instruments would have to be developed for each VAMC.

Neither of the two empirically based approaches is acceptable at present. The production function (PF) variant could not be estimated for any of the four specialties; the PF is specific to PCAs, and there is no single "dominant" PCA defined in the overall methodology for any of the four specialties. The inverse production function (IPF) can be satisfactorily estimated for each of the specialties. But the IPF (like the PF) relies heavily on staffing data from the VA's Cost Distribution Report (CDR), whose reliability the panel regards as variable at best, and specifically unreliable in these hospital-based specialties.¹

Though the panel did not feel the need to adopt such an approach, it does see the merits of a version of the Reconciliation Strategy in which FTEE requirements are computed as a weighted average of expert judgment and statistical modeling results—especially for establishing reasonable initial increments, or decrements, in physician staffing relative to the status quo.

An empirically based, rather than expert judgment-based, approach should be adopted for determining FTEE allowances for research. The most straightforward, reasonable procedure is to assign each specialty that amount of research FTEE allocated on the facility's CDR in the previous fiscal year. An alternative, and preferable, approach is to make these FTEE allocations dependent on quantitative measures of research productivity, such as grant funding levels and research publications.

All VA physicians should be expected to receive some minimum amount of continuing education annually as an important part of an overall quality assurance program. This minimum FTEE commitment to continuing education should not vary by specialty or facility. The VA could base these FTEE allocations on standards established by the specialty boards for recertification, by the states for maintaining licensure, or by the American Medical Association for its Physician Recognition Award for Continuing Medical Education.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be set globally, perhaps equated to an overall average computed across the VA system.

Assuming an adequate availability of residents, none is required. The panel notes, however, that this is a significant assumption and may not hold for all VAMCs, especially the smaller facilities.

Assuming the VA is adequately staffed with VA physicians, there is no need for additional C&A and WOC FTEE to handle the quantity of workload presenting. However, these non-VA physicians can serve to enhance both the quality of patient care and educational opportunities for VA staff physicians and residents.

In a strictly mechanical sense, non-VA staffing standards were successfully applied to determine the implied appropriate staffing at VAMCs I, II, and III for each of the four specialties. The overall result is that, although a given VAMC was sometimes understaffed according to a particular criterion, there was no significant pattern of understaffing or overstaffing.

But the validity of these comparisons is threatened by some fundamental problems. For each of the four specialties, there are national guidelines relating workload to physician staffing, but it is not clear whether these make proper allowance for all of the patient care and non-patient-care duties expected of the VA staff physician. With external norms derived from staffing behavior observed at non-VA facilities, there are several difficulties. The definition of workload for the four specialties varies across non-VA facilities. There is no universal definition of an FTEE, and virtually no other institution attempts to define it with the precision of the VA. Similarly, few private-sector facilities have data systems that keep track of the allocation of physician FTEE to specific types of activities. Since few hospitals routinely study the relationship between workload and physician FTEE, the non-VA staffing ratios that do emerge are often roughly estimated on an ad hoc basis.

There was a general consensus among panel members that, for the three VAMCs studied in depth, there was a degree of understaffing (in FY 1989) in diagnostic radiology, nuclear medicine, and radiation oncology; laboratory medicine appeared neither significantly overstaffed nor understaffed in these facilities. However, the panel is unwilling at present to extend these conclusions to the VA system as a whole. A sample of three is too small for valid inferences.

If the SADI were applied across the system, the question of overall staffing adequacy could be directly confronted. But a large caveat would remain, at least in the short term, because still lacking is quantitative information linking

physician staffing intensity in these specialties to indicators of the quality of care. Evidence of such a linkage can be investigated only gradually over time, as quality of care indices are developed and their relationship to physician staffing levels investigated.

Panel members differed on whether it is better to report physician staffing recommendations in the form of a range of alternative values or as a single point estimate. Some argued in favor of point estimates because budget pressures will inevitably lead the VA decision maker to the low end of whatever range is presented. Others pointed out that, first, a range allows one to reflect the genuine uncertainty that exists about "the" appropriate staffing level and, second, the VA decision maker may not invariably choose the lowest point on the range.

The panel was impressed by the ongoing work in the VA's pathology service to develop a methodology to account for how laboratory medicine physicians allocate their time that is more detailed than what is currently available from the CDR, the DSE, or the SADI. (See the panel's report in Volume II, Supplementary Papers.) As the VA proceeds to refine the laboratory medicine SADI, it should investigate the development of time estimates at the level of task specificity found in the pathology service survey instruments.

For determining physician requirements in laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology, the panel endorses the variant of the Reconciliation Strategy described 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.6.

[Note: A more complete discussion of these results is found in the panel's report to the study committee; see Volume II, Supplementary Papers.]

To determine the number of physicians required for the ambulatory care program at VAMCs, the panel endorses the study committee's proposed Reconciliation Strategy. Regarding the components of the strategy, the panel recommends the following:

To derive the level of physician FTEE required to care for a given patient workload, while residents are being trained and administrative duties are being handled, the panel recommends an expert judgment-based methodology built around the SADI. The DSE is an acceptable alternative methodology, but the SADI is the better approach for ambulatory care for several reasons.

The time (and hence, FTEE) required to deliver ambulatory care can be usefully conceptualized as the time to manage a sequence of patient visits, of varying complexity. Some will be initial visits, others followup. Some will be handled with residents and various nonphysician practitioners; others may involve primarily the physician. Some will be emergency, others routine. Depending on the patient's problem, different specialties (or mixes of them) will be involved. The degree of physician involvement in a given visit will be influenced by all of these factors. Because it focuses on the physician time required per visit or per procedure, the SADI methodology is thus well suited for computing physician requirements in ambulatory care. Unlike the DSE instrument, which is facility specific, the SADI is a generic construct that can be applied directly to any VAMC (assuming adequate information about outpatient workload, residents, and support personnel).

The application of the SADI to the ambulatory care program at VAMCs I, II, and III leads generally to plausible estimates of physician FTEE for patient care, resident education, and administration. The panel regards this as a fairly successful small-scale experiment; however, the validity and acceptability of the SADI methodology should be evaluated further through a much broader application involving a strategically chosen sample of VA ambulatory care programs.

Either form of the empirically based physician staffing model presents problems at present. Conceptually, the PF does offer an attractive approach for analyzing physician requirements in ambulatory care. All of the VA's clinic stops are mapped into six mutually exclusive and exhaustive PCAs, and one can calculate alternative combinations of provider types that are consistent with meeting patient workload in each PCA. Given certain assumptions, physician FTEE required by specialty can be deduced from these statistical analyses. But a major concern is that the FTEE data used in estimating these models may be

significantly flawed at present. The panel believes that physician FTEE devoted to ambulatory care is consistently undercounted in the current data system. Despite efforts to improve data collection at many VAMCs, there is insufficient uniformity in the way facilities allocate physician FTEE between inpatient and ambulatory care and among activity categories within ambulatory care. Because the PF model requires FTEE broken out to this level of detail, the issue is important. Correspondingly, if CDR record keeping continues to improve over time, this objection to the PF model should dissipate.

The IPF model is plagued by these same data difficulties, but it presents a more fundamental problem. Because the IPF equations presented to the panel do not allow physician FTEE to be analyzed by PCA, there is no appropriate IPF for ambulatory care. (However, the effect of outpatient workload on physician requirements is recognized in each IPF.)

Physician FTEE allocated to research should reflect a deliberate VA policy decision—not something determined mechanically from CDR data. The panel recommends that this determination be made by each facility with guidance from VA Central Office. Although a good research program will enhance the overall quality of ambulatory care at any VAMC, the panel acknowledges that the amount of FTEE allocated to research will—and should—vary significantly across facilities. In determining these FTEE, VA policy makers should be guided by measurable indicators of research productivity such as the level of VA and non-VA research funding. The strength of the VAMC's affiliation with a scientifically productive medical school is another potential indicator.

As with research, the commitment to continuing education should not be dictated by the status quo, but rather be the result of a conscious VA policy decision on what continuing education is required to promote high-quality care. At a minimum, the FTEE allocated to continuing education should be commensurate with the commitment required to maintain board certification in the specialties concentrated in ambulatory care. The panel strongly recommends that the continuing education allowance be greater than this minimum and be applied to all VAMCs, affiliated or not. Further, each VAMC should develop a vigorous continuing education program of its own and ensure that all staff physicians participate to a specified extent.

The percentage of total FTEE earmarked for vacation, sick leave, administrative leave, and other authorized absences should be established on the basis of existing VA regulations.

When emergency, admitting, or other ambulatory care areas are open, one or more staff physicians should be available either to provide patient care or to supervise the provision of patient care by residents or others. When availability cannot be provided by existing staff physicians—for example, when extensive coverage is needed in smaller institutions with few staff physicians—then additional physician availability should be arranged for nights and weekends by purchasing coverage from other physicians. The amount of purchased coverage will depend on the total number of hours of coverage needed, the number of staff physicians available to provide coverage, and the distribution of staff physician effort between night or weekend coverage and other duties. (At some VAMCs, this ''off hour'' coverage is provided by residents hired specifically for the task. In the future, quality management concerns and other factors may serve to reduce the role of residents in this area.)

In general, decisions about the purchase of additional coverage should be made by each VAMC following guidelines provided by VA Central Office.

These non-VA physicians enhance the quality of both patient care and resident education. Therefore, the need for these services may be greater in hospitals with more extensive teaching programs and in hospitals with limited types of specialists on their staffs. Decisions about the acquisition of C&A and WOC services should be made at each facility following guidelines provided by the VA. The panel notes also that compensation for C&A services has not been raised in many years; the fee remains $40/visit for attendings and $75 for consultants. The VA should strongly consider increasing these payment rates.

The panel reviewed non-VA staffing ratios (visits/MD) from five sources and also VA guidelines for ambulatory care issued about 25 years ago. Each of these "norms" was applied, in turn, to VAMCs I, II, and III to calculate the physician

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.

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.

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

one-shot affair. A thorough reassessment of the methodology and required data should be undertaken at least every 5 years.

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.]

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:

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.

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.

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.

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.

Assuming adequate support from medicine and the other services, no additional FTEE are required.

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.

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

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.

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.

The panel feels that there are at least seven issues requiring careful consideration as the VA continues to refine the proposed physician staffing methodology.

1. 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

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.

2. 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.)

3. 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.

4. 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:

1. Distinct, identified units where the LTC physician is responsible for providing primary care;

2. Distinct, identified units where the LTC physician has a consultative role only; and

3. 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.

5. 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

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?

6. 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.

7. 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:

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.

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.]