Physician Staffing for the VA

VOLUME I

Committee To Develop Methods Useful To the Department of Veterans Affairs in Estimating Its Physician Requirements

INSTITUTE OF MEDICINE

Joseph Lipscomb, Editor

NATIONAL ACADEMY PRESS
Washington, D.C.
1991



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Physician Staffing for the VA: Volume I Physician Staffing for the VA VOLUME I Committee To Develop Methods Useful To the Department of Veterans Affairs in Estimating Its Physician Requirements INSTITUTE OF MEDICINE Joseph Lipscomb, Editor NATIONAL ACADEMY PRESS Washington, D.C. 1991

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Physician Staffing for the VA: Volume I NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported by the U.S. Department of Veterans Affairs under Contract No. V101(93)P-1166. Library of Congress Catalog Card No. 91-62497 International Standard Book Number 0-309-04549-5 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Washington, DC 20418 S412 The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the staatlichemuseen in Berlin. Printed in the United States of America

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Physician Staffing for the VA: Volume I COMMITTEE TO DEVELOP METHODS USEFUL TO THE DEPARTMENT OF VETERANS AFFAIRS IN ESTIMATING TIS PHYSICIAN REQUIREMENTS DAVID R. CHALLONER (Chair),* Vice President for Health Affairs, University of Florida, Gainesville MARJORIE BEYERS, Associate Vice President for Nursing and Allied Health Services, Mercy Health Services, Farmington Hills, Michigan JO IVEY BOUFFORD, Director, King's Fund College, King Edward's Hospital Fund For London JOHN D. CHASE,* Dean Emeritus, School of Medicine, University of Washington, Seattle ROBERT M. DONATI, Executive Associate Vice President, St. Louis University Medical Center, St. Louis, Missouri JOHN W. ECKSTEIN,* Dean, College of Medicine, University of Iowa, Iowa City JACOB J. FELDMAN,* Associate Director for Analysis and Epidemiology, National Center for Health Statistics, Hyattsville, Maryland DANIEL W. FOSTER,* Professor and Chairman, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas ERNEST W. JOHNSON, Professor of Physical Medicine and Rehabilitation and Associate Dean for External Affairs, Ohio State University College of Medicine, Columbus ROBERT J. JOYNT,* Vice President and Vice Provost for Health Affairs, University of Rochester, Rochester, New York KERRY E. KILPATRICK, Chairman, Department of Health Policy and Administration, University of North Carolina, Chapel Hill DAVID J. KNESPER, Director, Division of General Hospital Services, Department of Psychiatry, University of Michigan, Ann Arbor W. EUGENE MAYBERRY,* Chairman, Board of Development, Mayo Foundation, Rochester, Minnesota J WARREN PERRY,* Professor and Dean Emeritus, School of Health Related Professions, State University of New York at Buffalo DAVID C. SABISTON, Jr.,* Professor and Chairman, Department of Surgery, Duke University Medical Center, Durham, North Carolina HAROLD M. VISOTSKY, Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Northwestern University, and Director, Institute of Psychiatry, Northwestern Memorial Hospital, Chicago, Illinois ALBERT P. WILLIAMS, Director, RAND Health Sciences Program (through November 1990); Corporate Research Manager, Social Policy, RAND (from December 1990), Santa Monica, California

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Physician Staffing for the VA: Volume I SANKEY V. WILLIAMS, Professor of Medicine and Director of Clinical Scholars Program, University of Pennsylvania, Philadelphia CHERYL E. WOODSON, Director, Fellowship Program in Geriatric Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois *   Member, Institute of Medicine STUDY STAFF Division of Health Care Services JOSEPH LIPSCOMB, Study Director (from July 1989) BOBBIE J. ALEXANDER, Staff Associate/Study Administrator JUDITH L. TEICH, Staff Officer (until December 1990) NANCY KADER, Staff Officer (from December 1989 until November 1990) ASHLIN HARMAN, Senior Secretary (from December 1989 until August 1990) H. DON TILLER, Administrative Assistant, Division of Health Care Services KARL D. YORDY, Director, Division of Health Care Services ITZHAK JACOBY, Study Director (until April 1989) DOROTHY AMEY, Staff Officer (until October 1989) JOHN VALENTINE, Staff Officer (until October 1989) CAROL MCKETTY, Research Associate (until July 1989) DELORES SUTTON, Senior Secretary (until March 1989) LESLIE SHERMAN, Secretary (until March 1989) Consultants KERRY L. LEE, Associate Professor of Biostatistics, Division of Biometry, Department of Community and Family Medicine, Duke University, Durham, North Carolina KAREN S. PIEPER, Statistician, Clinical Biostatistics, Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina WARREN E. CRANE, Computer Programming Consultant, Washington, D.C. WM. DANIEL CULVER, Program Analyst, Strategic Planning and Policy Office, Veterans Health Administration, Department of Veterans Affairs, Washington, D.C.

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Physician Staffing for the VA: Volume I PREFACE Unlike most Institute of Medicine (IOM) studies, which deal purely with policy choice, this project's task was to develop a method by which the Department of Veterans Affairs (VA) could determine its physician manpower requirements. The implications of this difference are significant. To construct a new state-of-the-art tool for calculating physician staffing requirements, by specialty and at the facility level, calls for an element of creativity in the development and use of quantitative analytic methods, data bases, and professional judgment. While these efforts taxed both committee and staff, they responded admirably and have broken new ground. The VA manages this country's largest and, arguably, one of the world's most important health care systems. It is critical for the VA's future that it have a sound plan for determining the number of physicians required for its three mission-connected responsibilities of patient care, education, and research. We believe we have created a tool for determining physician requirements that will be of great utility to VA decision makers in their policy roles. The committee's background varied from "quantniks" to bedside physicians of many specialties. It took a significant effort to marshall this expertise to produce an approach that is methodologically innovative, capable of being applied systemwide in a relatively efficient fashion, and sufficiently detailed and concrete to be relevant to the realities of the clinical environment. Here also the members of the committee enriched each others' experience and understanding. No one could have asked more of a committee and its panels. My thanks go to Sam Thief who was supportive over a longer-than-usual IOM project and who understood the uniqueness and complexities of our task. Division director Karl Yordy personally added his considerable experience to our effort, and the committee is grateful. However, to Joe Lipscomb, the staff director, go the committee's and my own personal thanks, admiration, and even

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Physician Staffing for the VA: Volume I awe. His prodigious efforts made this complex project run smoothly. More important, he was a nidus of creativity around which the committee's efforts crystallized. He was vigorously seconded by Bobbie Alexander and the rest of the staff. In all my years of involvement in IOM endeavors, I have never seen such a hard-working group. Now we pass the baton back to the VA. David R. Challoner, Chair Committee to Develop Methods Useful to the Department of Verterans Affairs in Estimating Its Physician Requirements

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Physician Staffing for the VA: Volume I ACKNOWLEDGMENTS This study could not have been accomplished without the assistance of numerous individuals in VA Central Office and VA medical centers around the country. The committee is especially indebted to the leadership and staff of the VA's Boston Development Center (Braintree, Massachusetts) for their unfailing diligence in providing the data and interpretive expertise that enabled the committee to produce the empirically based physician staffing models. Deserving of special praise are the contributions of Frank Holden, the center's director, and of Stephen Kendall and Michael Doyle. The committee is grateful to the administrative and clinical officials at the four VA medical centers (labeled in the report as VAMCs I, II, III, and IV) whose locally generated data were crucial to the development of accurate depictions of these facilities in the expert judgment staffing exercises. Over the course of the study, committee and panel members and staff conducted site visits at 16 different VA medical centers across the country. To the VA professionals who participated in the organization and conduct of these visits, the committee owes special thanks. The committee also expresses its appreciation to the administrative and clinical professionals in the 60 VAMCs that participated in surveys conducted by the affiliations and nonphysician practitioners panels. The VA Liaison Committee, chaired by Elizabeth Rogers, offered the committee thoughtful commentary, and encouragement, throughout the study. This group of VA clinicians, administrators, and health services researchers improved the committee's understanding of the rapidly changing VA health care system and the role that a physician staffing methodology might play in it. From the project's beginning to its conclusion, the committee has greatly benefited from the advice and support of its VA project officer, Gabriel Manasse. No one has had a better understanding of the subtle complexities—both administrative and clinical—that have characterized this complicated and lengthy endeavor. He, of course, does not shoulder the responsibility for what

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Physician Staffing for the VA: Volume I the committee produced, but he has most certainly enhanced the quality of the product. Finally, the committee expresses its deep appreciation to the members of the 11 panels appointed to advise this study. For their diligence and intellectual leadership, the chairs of these panels deserve special recognition: Robert M. Donati (other physician specialties); Daniel W. Foster (medicine); Ernest W. Johnson (rehabilitation medicine); Robert J. Joynt (neurology); Kerry E. Kilpatrick (data and methodology); W. Eugene Mayberry (affiliations); Harold M. Visotsky (nonphysician practitioners); Harold M. Visotsky and co-chair Robert L. Leon (psychiatry); David C. Sabiston, Jr. (surgery); Sankey V. Williams (ambulatory care); and Cheryl E. Woodson (long-term care). For excellent editorial assistance, the committee thanks Julie Phillips, consulting editor; Leah Mazade, IOM staff editor; and Wallace K. Waterfall, director of the IOM Office of Communications.

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Physician Staffing for the VA: Volume I CONTENTS     EXECUTIVE SUMMARY   1     Overview of the Study   1     Purpose and Scope   1     Organization and Conduct of the Study   1     Some Undergirding Assumptions   2     Defining, Building, and Reconciling Alternative Approaches to Physician Staffing   4     Three General Approaches to Determining Physician Requirements   4     The Empirically Based Physician Staffing Models   5     Expert Judgment Models   5     Reconciling the Approaches   6     Using the Reconciliation Strategy to Calculate Physician FTEE   7     External Norms   8     Overall Adequacy of Physician Staffing in the VA: Committee Perspective   8     VA Central Office and the VAMC: Promoting a Dialogue   9     Affiliations with Medical Schools   9     Nonphysician Practitioners   10     Further Development of the Methodology   10     Concluding Remarks   11 1   OVERVIEW OF THE STUDY   13     Purpose and Scope   13     Organization and Conduct of the Study   15     The Committee Perspective   17     References   18 2   BACKGROUND   19     Current Allocation of Physicians in the VA   19     Total Physicians, by Specialty   19

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Physician Staffing for the VA: Volume I     How Physician FTEE Levels Currently Are Determined   20     Some Undergirding Assumptions   22     The Methodology Focuses on Physician FTEE for VAMCs   22     This Is Not a Needs-Based Approach   23     Assuring the Quality of Care   24     The Methodology Must Be Relevant to the Present, Flexible for the Future   25     References   27 3   OVERVIEW OF THE ANALYSIS   29     A Central Problem: Determining Physician FTEE Required for Patient Care and Resident Education   30     Determining Physician Requirements for Other Mission-Related Activities   34     Reconciling the Approaches   35     Management Uses of Physician Staffing Models   36     Projecting Future VA Patient Workload   37     The VAMC-Medical School Affiliation Relationship   38     Nonphysician Practitioners and VA Physician Requirements   38     Committee Conclusions and Recommendations   39     Reference   40 4   THE EMPIRICALLY BASED PHYSICIAN STAFFING MODELS   41     How the Empirically Based Models Work   43     Anatomy of the PF Variant   44     Anatomy of the IPF Variant   49     Formal Presentation of the EBPSM   52     Production Function   52     Inverse Production Function   56     Using VA Data to Assign Values to Variables   59     Workload   59     VA Staff Physician FTEE   64     Nurse FTEE   65     Support-Staff FTEE   66     Contract Physician FTEE   66     Resident FTEE   66     Nonpersonnel Factors Influencing Physician Productivity   67

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Physician Staffing for the VA: Volume I     Estimated PF and IPF Equations   68     PF Estimates   69     IPF Estimates   84     EBPSM Application 1: Using the Models to Assess Physician Staffing Levels and Workload Productivity at VAMCs   94     Using the IPF to Compare Predicted and Actual Physician FTEE Devoted to Direct Patient Care and Resident Education   95     Using the PF to Compare Projected and Actual Physician FTEE Devoted to Direct Patient Care   97     Using the PF to Compare Predicted and Actual Rates of Workload Productivity   99     EBPSM Application 2: Derivation of Future Physician Requirements, by Specialty, for VAMCs   100     Using the IPF to Derive Future Physician Requirements for Direct Patient Care and Resident Education   100     Using the PF to Derive Future Physician Requirements for Direct Patient Care   102     Proposals for Refining and Extending the EBPSM   103     Improving the Accuracy of Data from the CDR   103     Developing Improved and New Variables for the Models   104     Further Methodological Development   106     References   106 5   EXPERT JUDGMENT APPROACHES TO PHYSICIAN STAFFING   151     Introduction   151     The Panel Process—In Theory   154     Scheme for Eliciting Judgments   154     Reaching a Consensus   156     Committee's Proposed Approach to Eliciting Expert Judgments and Reaching Consensus   158     The Panel Process—In Practice   159     Appointment of Specialty and Clinical Program Panels   160     Evaluating the EBPSM   161     Development of the DSE   162     The SADI   167     External Norms   173     References   175

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Physician Staffing for the VA: Volume I 6   CHOOSING AMONG ALTERNATIVE APPROACHES TO DETERMINING PHYSICIAN STAFFING   221     Strategies for Reconciling the Approaches   221     The Reconciliation Strategy   223     Committee's Recommended Approach   223     Interpretation of the Strategy   224     Using the Reconciliation Strategy to Calculate Physician FTEE   229     External Norms   240     Overall Adequacy of Physician Staffing in the VA: Committee Perspective   241     Illustration of Reconciliation Strategy Calculations   244     Current Staffing   244     The Reconciliation Strategy   245     Physician FTEE Calculations Oriented Around the Empirically Driven Baseline (X1)   245     Physician FTEE Calculations Oriented Around the Expert Judgment Element of the Modifier (X2)   247     Physician FTEE Calculations from the Perspective of the Reconciliation Strategy   249     Reference   251     Appendix—Specialty and Clinical Program Panel Conclusions   252     Medicine Panel   253     Surgery Panel   258     Psychiatry Panel   264     Neurology Panel   270     Rehabilitation Medicine Panel   275     Other Physician Specialties Panel   279     Ambulatory Care Panel   285     Long-Term Care Panel   291 7   MANAGEMENT USES OF THE PHYSICIAN STAFFING METHODOLOGY   299     VA Decision Makers in Central Office and the VAMCs: Promoting a Dialogue   299     Use of Models in Management Decision Making   302     The Physician Staffing Methodology as a Component of a VA Decision Support System   303

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Physician Staffing for the VA: Volume I     Applying the Methodology to Resource Management Questions   304     Sensitivity Analysis   304     Outlier Analysis: Comparing Actual Versus Model-Predicted Values for Physician FTEE and Patient Workload   308     Choosing an Optimal Specialty Mix of VA Physicians Through Linear Programming   310     References   314 8   PROJECTING FUTURE PATIENT WORKLOAD   321     Inpatient Workload   324     Projections for the EBPSM   324     Projections for the Expert Judgment Approaches   329     Ambulatory Care Workload   331     Projections for the EBPSM   331     Projections for Expert Judgment Approaches   334     Long-Term Care Workload   335     Projections for the EBPSM   335     Projections for the Expert Judgment Approaches   339     A Caveat   340     References   341 9   AFFILIATIONS WITH MEDICAL SCHOOLS   343     Significance of Affiliations for This Study   343     Issues Concerning Affiliations   344     Committee Approach to These Issues   345     Background and History of VA-Medical School Affiliations   346     Major Issues on Affiliations   348     Direct Effects of Affiliations on Physician Requirements   348     Cost Effects of Affiliations   350     Benefits to Patient Care of Affiliations   351     Problems in Meeting the Full Range of Patient Care Needs   353     Research, Education, and Backup to the Department of Defense as Part of the VA Mission   354     Policy on Lack of Affiliation in Some Institutions   354     Conclusions and Recommendations   355     Value of Affiliations for the VA Health Care System   355     Development and Expansion of Affiliations   356     References   357

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Physician Staffing for the VA: Volume I 10   NONPHYSICIAN PRACTITIONERS   363     Defining the NPP and the Focus of the Analysis   364     Inferences from the NPP Surveys   366     Conclusions and Recommendations   368     Integration of NPPs into the Physician Staffing Methodology   368     Continuing Education for Physicians and NPPs   369     A National Policy for Appropriate Utilization of NPPs   370     Additional Studies and Analyses   371     References   372 11   CONCLUSIONS AND RECOMMENDATIONS   373     Choosing Among Alternative Approaches to Physician Staffing   375     Using the Reconciliation Strategy to Calculate Physician FTEE   379     Total Physician FTEE (VA and Non-VA) for Direct Care, Resident Education, Administration, and Leaves   379     Staff Physician FTEE for Research   383     Staff Physician FTEE for Continuing Education   384     External Norms   384     Committee Perspective on Overall Adequacy of Physician Staffing in the VA   385     VA Central Office and the VAMC: Promoting a Dialogue   387     Projecting Future VA Patient Workload   389     Affiliations with Medical Schools   389     The Value of Affiliations for the VA Health Care System   389     Development and Expansion of Affiliations   390     Nonphysician Practitioners   391     Integration of NPPs into Physician Staffing Methodology   391     Continuing Education for Physicians and NPPs   392     Setting National Guidelines for Appropriate Scope of Practice for NPPs   393     Additional Studies and Analysis   393     Further Development of the Physician Staffing Methodology   394     Refining and Extending the EBPSM   394     Evaluating and Refining the SADI   396

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Physician Staffing for the VA: Volume I     External Norms   398     Extending the Workload Projection Models   398     Moving the Process Forward   399     References   399     APPENDIXES   401     A Rosters of Study Committee Panels and VA Liaison Committee   403     B List of Abbreviations   413

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