11
CONCLUSIONS AND RECOMMENDATIONS

In this final chapter of the report, the committee presents its conclusions and recommendations on how the Department of Veterans Affairs (VA) should determine physician requirements. Also summarized are the committee's views on two important related topics, VA-medical school affiliations and nonphysician practitioners.

Most of the points below, and the committee's reasoning behind them, have already appeared in the course of the first 10 chapters. However, a question not addressed earlier concerns the steps the VA should take to ensure that the physician requirements methodology is further refined in the near term, then maintained and improved over time. This issue is discussed near the end of the chapter.

As a prelude, the main elements of the committee's charge are reiterated.

The central purpose of this study has been to develop a methodology to assist the VA in answering a basic, but extraordinarily complex, question: To accomplish its principal mission-related responsibilities of patient care, education, and research, how many physicians does the VA require?

Specifically, the VA asked the Institute of Medicine (IOM) to develop "a sound methodology for estimating the number of physicians, by specialty groupings, required for the efficient delivery of high quality physician services" (Institute of Medicine, 1987) in all programs and facilities operated by the Veterans Health Administration (VHA), which has responsibility for all VA physician-related activities.

The VA designated as the primary objective for the study the development of a "mathematical/statistical methodology, incorporating both empirically derived and professional judgment based values in the methodology's algorithms, which translates quantitative measures of ... mission related workload demands . . . into numerical estimates of physician staff requirements" (Institute of Medicine, 1987). Data for these analyses would be derived from three sources:



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Physician Staffing for the VA: Volume I 11 CONCLUSIONS AND RECOMMENDATIONS In this final chapter of the report, the committee presents its conclusions and recommendations on how the Department of Veterans Affairs (VA) should determine physician requirements. Also summarized are the committee's views on two important related topics, VA-medical school affiliations and nonphysician practitioners. Most of the points below, and the committee's reasoning behind them, have already appeared in the course of the first 10 chapters. However, a question not addressed earlier concerns the steps the VA should take to ensure that the physician requirements methodology is further refined in the near term, then maintained and improved over time. This issue is discussed near the end of the chapter. As a prelude, the main elements of the committee's charge are reiterated. The central purpose of this study has been to develop a methodology to assist the VA in answering a basic, but extraordinarily complex, question: To accomplish its principal mission-related responsibilities of patient care, education, and research, how many physicians does the VA require? Specifically, the VA asked the Institute of Medicine (IOM) to develop "a sound methodology for estimating the number of physicians, by specialty groupings, required for the efficient delivery of high quality physician services" (Institute of Medicine, 1987) in all programs and facilities operated by the Veterans Health Administration (VHA), which has responsibility for all VA physician-related activities. The VA designated as the primary objective for the study the development of a "mathematical/statistical methodology, incorporating both empirically derived and professional judgment based values in the methodology's algorithms, which translates quantitative measures of ... mission related workload demands . . . into numerical estimates of physician staff requirements" (Institute of Medicine, 1987). Data for these analyses would be derived from three sources:

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Physician Staffing for the VA: Volume I The VA's own information systems, reflecting what may be characterized as "internal" performance norms; "External" (to the VA) physician performance norms, as gathered directly or else inferred from other public-and private-sector health care organizations; and Expert panels, which would evaluate the models, the data used in them, and external norms—and, in light of these assessments, recommend modifications to either the models or their physician staffing recommendations. The committee determined that the overall methodology should be capable of assessing: The number of physicians required, at the present time, to meet the current patient care workload at VA medical centers (VAMCs). These assessments would be conditional on assumptions about the scope and case acuity of the workload; number and type of residents; availability of nonphysician resources (nurses, support staff, and other productivity-influencing factors); and the commitment of the VAMCs to teaching, research, continuing education, and other activities beyond direct patient care. Future VA physician requirements, taking explicit account of possible changes in the volume, mix, and case acuity of service demands resulting from the aging of the veteran population. The methodology should likewise be flexible enough to incorporate (in the future) projected changes in other factors influencing utilization, such as the distribution of veterans across eligibility-for-care categories and the proportion of females in the eligible population. The net effect on VA staff physician requirements of possible changes in the number, type, and intensity of VA-medical school affiliation relationships. In addition, there should be analyses of the potential effect of such changes on the VA's ability to accomplish the physician education component of its mission, both now and in the future. Over the years, the VA has published staffing guidelines for most health care provider categories, but not for physicians. This omission reflects the genuine complexities—clinical, economic, administrative, political—that abound in attempting to estimate just how many doctors are required to meet the VA's mission. In the majority of VAMCs, that mission is multipurpose: patient care, education, and research. In most of these activities, the VA staff physician is not a solo performer but works with a number of others—residents, non-VA consulting physicians, nurses, nonphysician practitioners, and other support staff. Hence, the number of staff physicians required, in any specific context, will be influenced by the availability and productivity of these other providers, who may function as complements to or substitutes for staff physicians. Nonpersonnel

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Physician Staffing for the VA: Volume I factors, such as the availability of critical capital equipment or floor space, may also be important. The amounts of time set aside for research, classroom instruction, continuing education, administrative activities, and professional development all should figure directly into the computation of total physician requirements. CHOOSING AMONG ALTERNATIVE APPROACHES TO PHYSICIAN STAFFING The central issue facing the VA decision maker is determining which methodological approach(es) should be adopted. Three general approaches were investigated: The analyses in chapter 4 demonstrated how physician requirements can be derived from statistical models estimated from existing VA data. Specifically, the committee developed the 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 formulations of an expert judgment model for physician staffing were introduced—one based on the Detailed Staffing Exercise (DSE) and the other on the Staffing Algorithm Development Instrument (SADI). Another 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. The committee rejects this option—and all others not based on operating principles that are clearly specified, logically defensible, 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 to derive the total physician Full-Time-Equivalent Employees (FTEE), by specialty, required for a given VAMC. The strategies called, in turn, for the VA decision maker to Adopt one dominant approach for each specialty (e.g., medicine) or clinical program area (e.g., ambulatory care). For example, the core of the methodology could be an empirically based model, but expert panels could be appointed to evaluate its staffing recommendations—and the model itself. Whether or not all specialties and program areas would be guided by the same dominant approach would be a separate decision.

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Physician Staffing for the VA: Volume I 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. Instead, the VA decision maker would have a menu of physician staffing estimates, each defensibly derived, from which to choose. 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 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. These techniques were discussed and illustrated in chapter 7. 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 integration could be accomplished 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 VA specialty or a program area at the VAMC would be the sum of these weighted components. The sensitivity analyses noted 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. In chapter 6, this was termed the Reconciliation Strategy. The formulation of the strategy presented there is reproduced below using (for illustration) internal medicine, the PF variant of the EBPSM, and the SADI variant of the expert judgment models: where X1 = total internist FTEE (staff, contract, non-VA consultants), as derived from the PF variant of the EBPSM and other facility-specific data, for direct care on medicine inpatient and

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Physician Staffing for the VA: Volume I     outpatient patient care areas (PCAs), consultations on all other PCAs, resident training in PCAs and in classroom, administration by chief and others, and leaves of absence; X2 = the same as X1, but derived from the SADI; R1 = internist research FTEE, as derived from an empirically based approach; R2 = the same as R1, but derived from the SADI; C1 = internist FTEE for continuing education, as derived from an empirically based approach; C2 = the same as C1, but derived from the SADI; and b, c, d = weighting parameters, each lying on the [0,1] interval. By varying the parameters b, c, and d jointly across their ranges (the unit interval in each case), a corresponding range of physician FTEE estimates is generated. Regarding the interpretation of the Reconciliation Strategy, the committee emphasizes the following: The formula for deriving FTEE in each of the three components of Equation 6.1 consists of two terms, 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—either the IPF or the PF. The second step is to investigate whether the Baseline FTEE estimate should be modified in light of factors threatening the validity of the empirically based model. As discussed in chapters 3 and 5, these factors fall into two broad groups of data-related problems—simple measurement and recording errors, and "clinically inappropriate" observations relating physician FTEE and workload (i.e., input-output relationships skewed by 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.

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Physician Staffing for the VA: Volume I 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 an empirically based model—if the important statistical and clinical assumptions are met. If they are not, then modification of the empirically driven estimates, whether through expert judgment staffing assessments or the application of external norms, is in order. Operationalizing the Reconciliation Strategy would require 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. 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. 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 that 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. Some observers might point out, with concern, that this framework is so flexible that it fails to constrain the VA decision maker—that virtually any FTEE level could be selected. There are two responses to this. First, to determine physician requirements according to the version of the Reconciliation Strategy is to work within the FTEE boundaries established by the empirically based and expert judgment models, specifically the PF, IPF, SADI, and DSE approaches. Not every physician allocation is compatible with the Reconciliation Strategy. Second, the VA decision maker already possesses the authority to establish physician staffing levels. The relevant issue for the committee was how data, from a variety of sources, might best be analyzed and evaluated to derive physician FTEE levels that are "most appropriate" by criteria that are well defined and openly acknowledged. It follows that the Reconciliation Strategy should not be viewed as a preset staffing formula, but as a framework for choosing FTEE requirements. It frequently would not be practical for a VAMC to realize instantaneously the new "target" level of physician staffing in a given specialty that emerges from application of the Reconciliation Strategy. To achieve and

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Physician Staffing for the VA: Volume I then accommodate any significant increase in physician FTEE, additional physicians must be recruited; and some adjustments would likely be required in support personnel, equipment, or space. 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. USING THE RECONCILIATION STRATEGY TO CALCULATE PHYSICIAN FTEE Within the "umbrella" of the Reconciliation Strategy, how exactly (by specialty and program area) should VA physician FTEE levels be calculated? On this, the committee sought and received advice from its six specialty and two clinical program panels. Their detailed recommendations are included in Volume II, Supplementary Papers, and summarized in the appendix to chapter 6 of this report. The study has benefited greatly from the panels' analyses and recommendations. But the committee underscores that the conclusions reported below are entirely its own, reflecting, it is hoped, a balanced and multidisciplinary perspective. The discussion below is organized around the three FTEE components delineated in Equation 6.1. Total Physician FTEE (VA and Non-VA) For Direct Care, Resident Education, Administration, and Leaves The eight panels have demonstrated on a small scale the types of analyses that the VA decision maker should undertake to determine physician requirements across the system for this dominant component of FTEE. For each of three actual VAMCs studied in depth (four, in the case of psychiatry), the current physician staffing level (including physician FTEE not in the Cost Distribution Report) was noted; the PF and the IPF variants of the EBPSM were applied (as appropriate); and the DSE and the SADI expert judgment models

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Physician Staffing for the VA: Volume I 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 (see the appendix to chapter 6), all conducted their analyses within the framework of the Reconciliation Strategy; so should the VA. The committee's main charge was to develop a methodology, not implement it. The panels' main charge was to test and refine the methodology. Only after the Reconciliation Strategy has been applied to a significantly larger sample of VAMCs will there exist the breadth of empirical information required to reach a generalizable conclusion about whether the PF, IPF, DSE, SADI, or some weighted combination of these is preferred for a given specialty or program area. On the basis of the analyses summarized in chapters 4 through 7, the committee reached the following conclusions regarding empirically based and expert judgment approaches to analyzing this major component of physician FTEE: The PF and the IPF are potentially complementary variants of the EBPSM, and either is a viable candidate for helping generate the Baseline estimates for this component of physician FTEE. The PF allows physician FTEE to be derived by PCA within the VAMC, while taking account of the productive contributions of residents, nonphysician providers, and other factors. 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. Hence, for laboratory medicine, diagnostic radiology, nuclear medicine, radiation oncology, and anesthesiology, no PF model was presented. In addition, physician FTEE will be acknowledged in the PF model only to the extent that it is associated statistically 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; when total required FTEE for that specialty is subsequently derived for the facility, none will be shown associated with that PCA. As specified in this study, the IPF generates a 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 Cost Distribution Report (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).

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Physician Staffing for the VA: Volume I However, no acceptable IPF model can be estimated for VA program areas that are multidisciplinary. Thus, there is no IPF presented for either ambulatory care or long-term care. 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. 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. Task time estimates were derived exhibiting strong face validity and yielding physician requirements for selected VAMCs that were generally plausible and acceptable to panel participants (see chapter 5 and the appendix to chapter 6). 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. 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. Because DSEs would have to be individually crafted for each VAMC assessed, applying this instrument across the system would be cumbersome and labor intensive. Hence, 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 in how well staffed they are relative to the system norm, in the accuracy of the CDR data allocating physician FTEE to activities and PCAs, and in factors affecting staffing that may

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Physician Staffing for the VA: Volume I not be captured in any data base. 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 Modifier terms in Equation 6.1. The proposed methodology is intended to help the VA determine the quantity of physicians, measured in FTEE, required to meet the mission-related demands of the VAMC. But, the committee does recognize that staff physicians in full-time administrative positions in Central Office and at other sites external to the VAMC have contributed significantly to patient care, education, and research. However, the committee regards the determination of FTEE for these purposes as traditionally a matter of administrative discretion and, in any event, beyond its technical competence. Similarly, although determining physician FTEE for full-time administrative positions at the VAMC does fall within the committee's defined purview, that, too, is better calculated on a site-by-site basis rather than through the application of formal staffing models.1 1    1. In chapter 6, the committee offers its own detailed recommendations for how physician FTEE should be computed for the following subcomponents of component X: Staff Physicians—Direct Care (across all PCAs), Education of Residents, Administration, Leaves of Absence; Contract Physicians; Purchased FTEE for Night and Weekend Coverage; and Consulting and Attending (C&A) and Without-Compensation (WOC) Physicians. For staff physician FTEE devoted to direct care, to resident education, and to administration, the nature of the required calculation depends in each case on whether the Reconciliation Strategy is to be implemented using the PF, IPF, SADI, or DSE—or some weighted average of an empirically based and an expert judgment model. As noted again in the text above, the committee regards both the PF and IPF as viable empirically based models; between the two expert judgment approaches, the SADI is preferred. However, for a given specialty or clinical program, the relative weight assigned to the Empirically Driven Baseline versus the (expert judgment) Modifier in the Reconciliation Strategy should, in principle, be determined by the VA decision maker on a site-by-site basis. As discussed in Chapter 6, the choice of procedures to calculate FTEE for contract physicians and C&A and WOC physicians depends in both cases on whether an empirically based or expert judgment approach—or some weighted combination—is chosen. However, the committee did make additional specific recommendations in chapter 6 regarding the computation of certain of the subcomponents of X: In the expert judgment staffing models, the leaves-of-absence component of total physician FTEE should be calculated as the FTEE equivalent of the annual leave to which the VA physician is entitled. (In the empirically based models, the FTEE allowance for leaves is presumably already reflected, implicitly, in the observed data.)

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Physician Staffing for the VA: Volume I Staff Physician FTEE for Research The amount of research FTEE built into overall physician requirements should be related to measurable indicators of research productivity and excellence. Not all VAMCs should be accorded 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, or (most simply) the amount of FTEE currently allocated by the specialty to research in the VA CDR. 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. When computing physician requirements through either the SADI or the DSE expert judgment approaches, additional FTEE for off-hour (night and weekend) coverage should be incorporated only for the emergency and the admitting & screening functions of ambulatory care. 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 physicians. Hence, no further FTEE adjustments to either empirically based model is required to account for night and weekend coverage.

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Physician Staffing for the VA: Volume I A wide spectrum of services provided by a pool of highly qualified physicians, both those on the VA staff and those whose services are made available to the VA through other relationships with the medical schools; Access to state-of-the-art tertiary care; Participation in the education of physicians, which is a mandated part of the VA mission and which cannot realistically take place currently in the absence of affiliations; Participation in medical and health services research, resulting in contributions to medical knowledge and improved health services, that benefits the general population as well as veterans. Underlying all of the above factors is the assumption, and some inferential indications, that affiliations contribute significantly to improving the quality of patient care. In other parts of this report, the committee has urged the VA to continue its work, being led by the VA Office of Quality Management, to develop quality-of-care indicators. These indicators will be critical not only for the full development of the physician requirements methodology, but also for a more definitive evaluation of the effect of affiliations. These analyses should focus not only on structure and process indicators of quality, but on outcome indicators that include, but go beyond, mortality measures. In these efforts, the VA should track closely the extensive efforts and developmental work being done by many health services researchers and health care organizations on outcome-related quality measures. Development and Expansion of Affiliations The committee recommends that the VA explore strategies for developing and expanding affiliations to include facilities that currently are not affiliated. This recommendation follows logically from the previous conclusion that affiliations bring benefits to the VA health care system. Given that conclusion, the committee believes that there is no logical reason not to provide at least some of these benefits to veterans cared for in all VA facilities. Such an expansion of affiliations would assist the recruitment and retention of high-quality staff and promote achievement of the other benefits outlined above. The committee further recommends that while maintaining and nurturing the current model of affiliations between VAMCs and medical schools, with its emphasis on tertiary care, the VA should work to develop innovative models of affiliation targeted specifically to the chronically ill, including those requiring psychiatric care and rehabilitation services. These innovative models would, in general, be oriented around and give emphasis to ambulatory and long-term care.

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Physician Staffing for the VA: Volume I The nature of the VA patient population presents special opportunities, and needs, for the development of new models. The Geriatric Research, Education, and Clinical Centers (GRECCs) serve to illustrate a successful model already developed by the VA to meet the particular needs of the population being served. Other opportunities—emphasizing a broad array of research related to these patient care needs, including health services research and research on health outcomes—could continue to make the VA health care system a resource for the benefit of the entire nation, as well as for veterans. Similarly, training opportunities focused in innovative ways on these particular patient care needs could make a major contribution to veterans and to the general population. The VA is in a logical position to support its own purposes and the purposes of the broader society. In developing these innovative affiliation approaches, the VA should explore the establishment of relationships with other medical institutions in addition to medical schools. The VA already has created the beginnings of a new model of affiliations with a recent program connecting VAMCs to community-based health care institutions not primarily related to medical schools. The committee believes that this type of extension represents an exciting opportunity that could help the VA meet its physician requirements, especially for primary care, in the years ahead. NONPHYSICIAN PRACTITIONERS Early in the study the committee hypothesized that VA physician requirements—at present, but especially in the future—may be influenced by the availability of certain nonphysician practitioners (NPPs). The committee's interest in NPPs was spurred by two considerations: (1) a substantial literature indicating that these practitioners can enhance physician productivity while maintaining the quality of care; and (2) the changing demographic structure of the VA patient population, which will increase the demand for ambulatory care and long-term care—arenas in which NPPs may be particularly productive. In chapter 10 the committee presented recommendations on the present and future role of four types of NPPs: physician assistants, nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists. Integration of NPPs Into Physician Staffing Methodology The committee believes that the degree to which these four types of NPPs are utilized either in complementary or substitutive roles has a direct effect on physician requirements. Therefore, the committee urges the VA to account

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Physician Staffing for the VA: Volume I more precisely for the influence of these NPPs, in both the empirically based and the expert judgment approaches to physician staffing, by incorporating the following: For the empirically based models, the VA should establish CDR cost centers for each of these NPPs. At present, the total FTEE of each type of NPP is available at the facility level, but not allocated across PCAs. If each NPP there were given a designated CDR cost center—as is the case presently for physicians (by specialty), nurses, psychologists, and social workers—it would be possible to analyze them explicitly in the PF and the IPF variants of the empirically based models. At present, these NPPs are reflected in the PF and IPF equations only through their inclusion in the SUPPORT/MD and NURSE/MD variables (see chapter 10). For the expert judgment models, NPPs are already explicitly recognized (see Figures 5.1 and 5.2). However, in subsequent versions of the SADI and the DSE that the VA may choose to create, these NPPs should be incorporated with greater specificity than at present. In particular, the assumed number of each of the four types in each relevant PCA should be built into these staffing instruments. Continuing Education For Physicians and NPPs From the NPP panel survey data and commentary, the committee concludes that the utilization of NPPs is more dependent on the particular attitudes and knowledge bases of individual physicians than on the training and clinical skill level of the NPP. Before the VA can begin to utilize NPPs in an efficient manner consistent with quality care, ongoing education programs for VA physicians must be established. The committee recommends that this physician education effort be initiated on an ongoing basis with a centralized program for senior VA management staff, and that, over time, programs be established at every VAMC. To support this recommendation of continuing education for physicians on the role and utilization of NPPs, the committee recommends that the VA pursue and establish, wherever possible, academic affiliations with these NPP training programs. The VA should also require and actively support the participation of NPPs in continuing education related to their roles and functions.

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Physician Staffing for the VA: Volume I Setting National Guidelines For Appropriate Scope of Practice For NPPs National guidelines on the use of NPPs should be strengthened where they exist, established where they do not, and updated on a regular basis over time. They should be orchestrated in a way that allows the VAMC adequate flexibility for innovation and quality control. As knowledge about the appropriate and effective use of NPPs continues to grow, the VA should periodically and thoroughly review its national policies on the use of these practitioners. For PAs and CRNAs, such policies already serve to establish the boundaries of practice, by listing specific permissible functions in various arenas of activity; the subset of these activities that may be delegated to the individual NPP has traditionally been determined entirely at the facility level. Because physician attitudes and knowledge bases regarding NPPs vary greatly across (and even within) VAMCs, there is wide variation in the activities actually performed by NPPs. This view was underscored in survey results presented to the committee by its NPP panel. As analyses emerge indicating that specified functions can be performed efficiently by NPPs with no anticipated loss in quality, the VA should give priority designation to these functions in its guidelines. This information should be communicated promptly to chiefs of staff, service chiefs, and clinicians (to the latter via the continuing education programs recommended above). Similarly, when the weight of evidence indicates that the NPP's performance of a function does not promote efficiency or quality, the function should be removed from the guidelines (if it was there); and this action also should be communicated promptly. The outcome of these studies should influence not only the specific functions that NPPs perform, but their overall roles vis à vis physicians in the patient care process. At present, explicit national guidelines on the utilization of NPs and CNSs do not exist. The committee urges the VA to develop such guidelines through a careful evaluation of existing evidence on their efficient and appropriate utilization. Additional Studies and Analysis To promote the development and diffusion of new information about the appropriate use of NPPs, the VA should support research projects that examine the range of activities now performed by these practitioners across the system. The focus should be on innovative uses of NPPs that hold promise for increasing access to care while not compromising quality. At present, there are numerous opportunities to observe NPPs in a variety of settings, in different specialties, and for various functions, inside as well as

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Physician Staffing for the VA: Volume I outside the VA. The VA should take advantage of these ''natural experiments'' to evaluate the appropriate (and inappropriate) uses of NPPs across a range of practice conditions. FURTHER DEVELOPMENT OF THE PHYSICIAN STAFFING METHODOLOGY The committee concludes that the task of developing a methodology to determine the number of physicians required by the VA is best pursued in an "evolutionary" fashion. The methodology recommended in this report should be regarded not only as a concrete beginning, but as a springboard to further experimentation and analyses. These would serve to test the validity of the statistical and expert judgment models as well as the overall appropriateness of staffing recommendations from clinical and economic perspectives. In the course of this report, the committee has presented a number of proposals for testing, refining, and extending the current methodology. In what follows, specific steps that the VA should take to launch this evolution are discussed. Refining and Extending the EBPSM The VA should test, evaluate, and revise (as needed) the EBPSM on an ongoing basis. With the demands on the VA health care system in dynamic transition, the EBPSM should not be treated as a static construct. Improving the Accuracy of Data from the VA CDR The VA should consider several options for strengthening the empirical foundation of these models: Each VAMC is now required to have a data validation committee. These committees should be actively encouraged to work aggressively at quality control. Positive incentives should be instituted for individual physicians and administrators to fill out CDR worksheets accurately—or penalties should be assessed for evident errors. For short, concentrated periods, physicians and administrators should be required to track how physician time is being allocated across activities; the results could be compared with the corresponding FTEE allocation in the CDR.

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Physician Staffing for the VA: Volume I Developing Improved and New Variables for the EBPSM The scope of the VA national data system should be broadened to permit the refinement of existing variables and the construction of potentially important new variables for use in the EBPSM: At present, it is not possible to distinguish full-time (FT) and various levels of part-time (PT) physician FTEE in the national CDR accounts, though the data are available in the VA payroll system. This information should be integrated into the CDR accounts to yield specialty-specific observations on the amount of physician FTEE, by FT or PT category, allocated to each PCA at all VAMCs. The CDR should be amended so that physician FTEE for resident education, research, and administration not occurring in the PCAs can be clearly distinguished. It is also not possible at present to distinguish physicians by subspecialty in the national CDR accounts. Investigations exploring the merits of including subspecialty FTEE in the PF equations and of producing IPFs specific to subspecialty should be undertaken, and they will require this more detailed FTEE data. The VA should strongly consider focused, time-limited surveys to collect information, by specialty, on the amount of FTEE contributed at VAMCs by C&A and WOC physicians. Data on the type, amount, and vintage of capital equipment affecting the efficient delivery of high-quality care should be made available for each PCA in all VAMCs. The CDR should be amended so that it is possible to obtain direct observations on the allocation of residency time, by postgraduate year (PGY), to all PCAs in the VAMC. As noted in the previous section, the VA should modify the CDR national accounts so that model-relevant FTEE data for four types of NPPs are available at the PCA level. This would require establishing distinct CDR cost centers for PAs, NPs, CRNAs, and CNSs. The strong statistical performance of most PF and IPF equations provides prima facie evidence supporting the validity of the workload measures used. But the VA should consider further analyses testing whether there are other output variables, derivable from existing VA data, that are more sensitively related to physician time requirements. Studies of the relationship between the intensity of physician staffing and indicators of the quality of care should be pursued, as indicated earlier.

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Physician Staffing for the VA: Volume I Further Methodological Development The committee recommends that the VA periodically review the selection of variables and functional form for each PF and IPF equation. Over time, a number of factors affecting the PF and the IPF equations can be expected to change, at varying rates: the mix and acuity level of cases presenting at VAMCs, medical technology, practice patterns, the range of services offered by the VA, and the quality and scope of data from the CDR and other sources. Consequently, it is important that all equations be reestimated periodically to test whether these various secular changes indicate that the models should be modified—either in their mathematical form or in the variables that make them up. The present data systems would permit reanalysis of these equations on an annual basis. Moreover, as multiple years (and, hence, samples) of data accumulate, it will become possible to undertake certain innovative, split-sample methods of internal model validation, such as bootstrapping. Evaluating and Refining the SADI The committee has recommended that the expert judgment component of the physician requirements methodology be built around application of the SADI. However, the committee does regard the SADIs developed in this study as first-generation instruments, requiring additional evaluation and refinement. Because the SADI approach emerged late in the study, it was not feasible to use a modified Delphi method, the committee's preferred approach, to derive physician activity-time estimates. The SADI estimates reported in chapter 5 and in the appendix to chapter 6 are based, instead, on staffing judgments elicited through one mail survey of all panel members; in a sense, they can be viewed as the results from the initial iteration of a modified Delphi process. To build upon this first-generation model, the committee recommends the following: The VA should proceed immediately to apply these SADIs to all VAMCs, or at least a large representative sample. For the four VAMCs analyzed by the specialty and clinical program panels, staff members were able to obtain the required facility-specific workload and related data by phone and mail (on a voluntary basis) in a matter of days. Following an evaluation of these applications, each SADI should be considered for revision. The focus initially would be on:

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Physician Staffing for the VA: Volume I Appropriate designation of activity time categories, with special attention to new programs and services (e.g., hospital-based home care); Appropriate specification of the type and the range of workload for each category, with special attention to whether case acuity is sufficiently differentiated; and Adequate delineation of factors influencing physician productivity, such as residents (by specialty and PGY), NPPs (by type), nursing and support staff, and certain items of capital equipment. The challenge is to construct a SADI with enough detail to capture significant distinctions while omitting factors that have little influence on physician time allocations. In this vein, the committee notes that throughout the study there was persistent discussion about the importance of nonphysician personnel of all types (nurses, various support staff, and NPPs—including psychologists and clinical social workers) in promoting the quality and efficiency of VA health care. The potential influence of these various providers on workload productivity was formally acknowledged in both the SADI and the EBPSM (particularly the PF variant)—to the extent that current data permitted. Subsequent versions of the SADI should be structured to examine more precisely the contributions of these nonphysician providers. This would require that physician activity times for each PCA be estimated as a function of the assumed mix of all nonphysician personnel (not just NPPs) judged to be pertinent to the appropriate operation of that PCA. Over time, the VA should investigate several other issues important to the validity, reliability, and relevance of the SADI approach, including: The reliability and consistency of the expert judges' physician activity time estimates; The feasibility of deriving from experts not simply point estimates, but probability distributions for the physician time required to perform various activities in the SADI. As discussed in Volume II, Supplementary Papers, such a probabilistic treatment of the SADI would permit the VA to develop statistical confidence statements about each of the staffing recommendations emerging from application of the instrument. The availability and appropriateness of observational (empirical) data from which to derive alternative estimates of these physician activity times; The subsequent integration of expert judgment and empirically derived activity time estimates through Bayesian statistical analysis (see Volume II, Supplementary Papers).

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Physician Staffing for the VA: Volume I External Norms To pursue the more detailed external norm analyses recommended by the committee, the VA should initiate a sequence of analyses as detailed below. Select a small number of clinical sites whose patient populations and scope of services are reasonably comparable to the VA's; From each site, collect data on workload, physician FTEE, nonphysician FTEE, and other descriptive information in sufficient detail that average physician time per unit of workload can be computed conditional upon patient characteristics (e.g., age, DRG classification); the availability of residents, nurses, NPPs, and support staff; and other productivity-influencing factors. These non-VA physician task times—which at this point would be at a level of detail comparable to those in the SADI—could be applied to the workload data from any given VAMC to derive an implied total quantity of physician FTEE required. This staffing estimate could then be compared with physician requirements for the facility as derived from the SADI and with the actual level of physician FTEE there. The VA should explore this and other scenarios for applying norms to all specialties and program areas. Extending the Workload Projection Models The precision and specificity, and thus the policy usefulness, of the workload projections required by the physician staffing models would be enhanced if veteran utilization of the VA system could be analyzed as a function of factors known to influence the demand for care. These include income, health insurance coverage, perceived quality of care, availability of alternative sources of care, and distance from the VAMC, as well as age, gender, and eligibility-for-care status. In addition, projection models such as those used by the VA currently and adopted here (see chapter 8) do not exploit the total information embedded in a given data set as efficiently as standard statistically based demand models. In particular, to investigate the joint and possibly interactive influence on utilization of two or more explanatory variables is a much more cumbersome undertaking. Statements about statistical precision and confidence are simply not possible with projection models since they are not derived statistically in the first place. The committee urges the VA to pursue the patient demand analyses described above.

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Physician Staffing for the VA: Volume I Moving the Process Forward There are a number of ways the VA could organize and support the analyses recommended above: a task force staffed principally from within the VA and coordinated through the office of the chief medical director; a targeted program of grants for which VA health services researchers, and possibly others, would be invited to compete; a program of contracts to perform specific analytical tasks related to testing or extending the methodology; or some combination of these approaches. With respect to these alternative approaches, the committee makes no specific recommendation. But it does recommend that the analyses proceed according to a two-phase process, defined roughly as follows: Phase I—an intensive period of analysis to evaluate and refine the SADIs, producing second-generation instruments in each case; to begin constructing new data and variables, as recommended, for the EBPSM; to undertake a more intensive application of external norms; and to produce first-generation versions of demand-based workload estimation models for inpatient, ambulatory, and long-term care. Phase II—an ongoing operation in which the VA (through its designated analysts) periodically reevaluates and possibly revises the SADIs, the EBPSM, external norms, and the workload models. The implications of these revisions for the content and execution of the Reconciliation Strategy would be analyzed. With the veteran population aging, with technology ever changing, with practice patterns evolving in the non-VA sector, it is crucial that the physician requirements methodology be reexamined on a regular basis. The committee estimates that Phase I could be completed within 24 months; Phase II would represent an ongoing commitment by the VA to ensure the continuing quality of its physician staffing policies. REFERENCES American Medical Association, Office of Physician Credentials and Qualifications. 1986. Information Booklet on the Physician Recognition Award. Chicago, Illinois. Institute of Medicine. 1987. Study Workplan (Statement of Work) for a Study to Develop Methods Useful to the Veterans Administration in Estimating its Physician Needs. Washington, D.C. Unpublished.

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