• 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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