Physician Staffing for the VA


Supplementary Papers

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


Joseph Lipscomb & Bobbie J.Alexander, Editors

Washington, D.C.

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Physician Staffing for the VA: VOLUME II Physician Staffing for the VA VOLUME II Supplementary Papers Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements INSTITUTE OF MEDICINE Joseph Lipscomb & Bobbie J.Alexander, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1992

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Physician Staffing for the VA: VOLUME II 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. 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 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 II COMMITTEE TO DEVELOP METHODS USEFUL TO THE DEPARTMENT OF VETERANS AFFAIRS IN ESTIMATING ITS 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 II 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 II INTRODUCTION This volume of Supplementary Papers is an important adjunct to the committee's report to the Department of Veterans Affairs on how the VA should determine its physician requirements (IOM, 1991). In Volume I the committee presented, and illustrated in detail, a methodology for calculating the number of physicians required, by specialty grouping, to meet the VA's mission-related responsibilities of patient care, education, and research. The methodology calls for statistically based and expert judgment approaches to be used in a flexible fashion to calculate the level of physician staffing required at a given VA facility, as a function of patient workload, teaching responsibilities, research commitments, and a host of other site-specific factors. In addition, the committee produced detailed recommendations regarding VA-medical school affiliation relationships and the use of nonphysician practitioners in the VA health care system. On each substantive topic examined in Volume I, the committee reached its recommendations only after careful consideration of the pertinent analyses and conclusions reported by one or more of its 11 advisory panels. Volume II consists largely of the final reports issued by these panels. Each report emerged from a number of months of careful deliberation, and each has been unanimously approved by the panel members. In Section I of this volume are the reports from the committee's six specialty panels—medicine, surgery, psychiatry, neurology, rehabilitation medicine, and other physician specialties (the latter focusing on laboratory medicine, nuclear medicine, diagnostic radiology, and radiation oncology) —and two clinical program panels—ambulatory care and long-term care. Sections II and III contain, respectively, the reports issued by the affiliations panel and the nonphysician practitioners panel. Finally, for the data and methodology panel—which played a major role in developing and integrating all components of the staffing methodology—there is no single final report. Rather, the

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Physician Staffing for the VA: VOLUME II contributions of this panel in working with the six specialty and two clinical program panels to develop empirically based physician staffing models are well reflected in each of these latter eight reports; it is also reflected in Volume I, both in chapter 4, where these data-driven models are analyzed in detail, and in chapter 7, where VA management uses of the models are illustrated. The final section of these Supplementary Papers reports additional analyses, completed since the publication of Volume I, that examine the statistical validity and physician productivity implications of a selected set of these empirically based models. As the committee report proper, Volume I was subject to the standard report review process required of all documents released by the Institute of Medicine with National Research Council approval. Because the panel reports and statistical analyses comprising Volume II were advisory to the committee, and do not necessarily reflect committee positions, these documents were not subjected to review by external reviewers in accordance with the the NRC report review process. While the panel reports presented in these Supplementary Papers were important to the committee's deliberations, the committee does not endorse any of the panel reports, as such. The chairs of the 11 advisory panels were drawn from the membership of the committee itself, so that the various perspectives emerging from each panel could be reflected directly in the committee process. While (by design) no member of the committee was on the clinical or research staff of a VA medical center during the study, each panel consisted (by design) of VA and non-VA members with the former never constituting a voting majority. In the end, the committee's conclusions represented committee consensus positions—not necessarily shared by the advisory panels. But the fruitful interplay between the committee and its panels was unmistakable and is well reflected in the pages of Volumes I and II. 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 VA Liaison Committee, chaired by Elizabeth Rogers, offered thoughtful commentary, and encouragement, throughout the study. This group of VA clinicians, administrators, and health services researchers improved the committee's and panels' 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 benefitted from the advice and support of its VA project officer, Gabriel Manasse. In this capacity, he served as an important information resource at

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Physician Staffing for the VA: VOLUME II panel meetings throughout the study, frequently contributing insightful observations and important clarifications. The committee thanks the 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. For his wise counsel and unfailing support throughout this long endeavor, the committee owes a special gratitude to Karl Yordy. For the statistical analyses that undergird the presentations in both Sections III and IV of this volume, the committee is grateful to Karen Pieper. The committee also thanks Don Tiller for his excellent administrative and publication support and assistance, and the IOM Office of Reports and Information for its continuing excellent editorial assistance. Finally, with the publication of Volume II, the committee expresses its deepest appreciation to the members of the 11 advisory panels. 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). REFERENCE IOM. 1991. Physician Staffing for the VA: Volume I. Lipscomb, J., ed. Washington, D.C.: National Academy Press. Joseph Lipscomb, Study Director David R.Challoner, Chair Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements

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Physician Staffing for the VA: VOLUME II This page in the original is blank.

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Physician Staffing for the VA: VOLUME II CONTENTS      EXECUTIVE SUMMARY   1      Overview of the Study   1      Defining, Building, and Reconciling Alternative Approaches to Physician Staffing   4      Overall Adequacy of Physician Staffing in the VA: Committee Perspective   9      VA Central Office and the VAMC: Promoting a Dialogue   10      Affiliations with Medical Schools   10      Nonphysician Practitioners   11      Further Development of the Methodology   12      Concluding Remarks   12  Section I:   Specialty and Clinical Program Panel Reports        OVERVIEW OF THE SPECIALTY AND CLINICAL PROGRAM PANELS   17      Introduction   17      Committee's Approach to Eliciting Expert Judgments and Reaching Consensus   19      The Panel Process—In Practice   20      References   33     Exhibit 1: Detailed Staffing Exercise (DSE) for the Medicine Panel and One Member 's Response   34     Exhibit 2: The Staffing Algorithm Development Instrument (SADI) for Medicine: The Complete Instrument with Statistical Summary of Panel's Assessments   56     Exhibit 3: Application of the SADI to Compute Physician Requirements in Medicine at VAMC I   68

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Physician Staffing for the VA: VOLUME II      MEDICINE PANEL REPORT   75      SURGERY PANEL REPORT   99      PSYCHIATRY PANEL REPORT   161      NEUROLOGY PANEL REPORT   207      REHABILITATION MEDICINE PANEL REPORT   237      OTHER PHYSICIAN SPECIALTIES PANEL REPORT   269      AMBULATORY CARE PANEL REPORT   311      LONG-TERM CARE PANEL REPORT   351     Section II: Affiliations Panel Report        AFFILIATIONS PANEL REPORT Karl D.Yordy and Judith L.Teich   395      Introduction   395      Background and History of VA-MedicalSchool Affiliations   396      Relationship of Affiliations to Physician Requirements   398      Major Issues with Regard to VA-Medical School Affiliations   399      Conclusions and Recommendations   412      References   416      Appendix: Survey of WOC Physician Time   417  Section III:   Nonphysician Practitioners Panel Report        NONPHYSICIAN PRACTITIONERS PANEL REPORT Bobbie J.Alexander and Joseph Lipscomb   421      Introduction   421      Defining the Nonphysician Practitioner   422      The NPP and the Physician Staffing Methodology   424      Surveys on the Current and Future Roles of Nonphysician Practitioners in the VA   425      Synopsis of Observations and Recommendations Contributed by Chiefs of Staff, Nonphysician Practitioners, Supervisors, and Panel Members   431      Panel Conclusions and Recommendations   438     Appendix A: Annotated Bibliography   447     Appendix B: Exhibits   457     Exhibit 1: Questionnaire for VA Nonphysician Practitioners   457

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Physician Staffing for the VA: VOLUME II     Exhibit 2: Questionnaire for Supervisors of VA Nonphysician Practitioners   463     Exhibit 3: Questionnaire for Chiefs of Staff   465  Section IV:   Further Examination of the Empirically Based Physician Staffing Models        Introduction   469      Overview of the EBPSM   470      Statistical Evaluation   472      Marginal Product Analysis   496      References   498  APPENDIX A:   ROSTERS OF THE DATA AND METHODOLOGY PANEL AND VA LIAISON COMMITTEE   531  APPENDIX B:   LIST OF ABBREVIATIONS   535

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Physician Staffing for the VA: VOLUME II