Physician Staffing for the VA: Volume II, Supplementary Papers (1992)

To accomplish its mission-related responsibilities of patient care, education, and research, how many physicians does the VA require?

The purpose of this study has been to develop a methodology to assist the Department of Veterans Affairs (VA) in answering this basic, but extraordinarily complex question.

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” in all programs and facilities operated by the Veterans Health Administration (VHA), which has responsibility for all VA physician-related activities.

The overall methodology should be capable of assessing:

• The number of physicians required to meet current patient-care workload at VA medical centers (VAMCs). These assessments would be conditional on the scope and case acuity of patient workload; the number and type of residents; the availability of nonphysician personnel, such as nurses, allied health professionals, and other support staff; and other productivity-influencing factors.

• Future VA physician requirements, taking into account possible changes in the volume, mix, and case acuity of patient workload resulting from the aging of the veteran population and other demographic and administrative factors.

• The net effect on VA 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 effects of such changes on the VA's ability to accomplish the physician education component of its mission now as well as in future years.

The IOM committee conducting this study consisted of 19 members, including experts in the physician specialties relevant to the VA, nursing, allied health manpower, statistics, economics, operations research, and health services research. Many members had, at some point, provided either patient care, clinical instruction, or research expertise at VAMCs. But, by design, no committee member was on the clinical or research staff of a VAMC during the period of the study.

The committee was advised by 11 panels: data and methodology (working on all components of the study, but focusing especially on statistical analyses), affiliations (examining VAMC-medical school affiliation relationships), nonphysician practitioners (focusing on a selected set of providers, including physician assistants and nurse practitioners), and six specialty and two clinical program panels (each concerned with physician requirements from the perspective of its own discipline or program).

The six specialty panels were medicine, surgery (which also included anesthesiology), psychiatry, neurology, rehabilitation medicine (which also included spinal cord injury), and other physician specialties (which included laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology). The two clinical program panels, both multidisciplinary in composition, were ambulatory care and long-term care.

Each panel consisted of a mix of VA-staff and non-VA members, with the former never constituting a voting majority. Each panel chair was also a member of the committee.

Throughout the study, the committee was advised also by a VA liaison committee, appointed by the VA chief medical director. Its 22 members, all VA professionals, included experts in the clinical specialties, administration, and health services research. The liaison committee 's role was strictly advisory, and the study committee benefited considerably from this group's thoughtful counsel.

The following assumptions were adopted by the committee in the course of the study:

• The Methodology Focuses on Physician Full-Time-Equivalent Employees (FTEE) Required to Meet the VA's Mission in the Field. The

IOM was not asked to compute the budgetary cost of the physician FTEE levels recommended by the methodology, or to analyze practical difficulties that might arise in acquiring these physicians. The methodology also does not examine how to determine the physician FTEE required for full-time administration at VA Central Office and other sites (including the VAMC). However, these are important issues that should be addressed squarely by the VA.

• This Is Not a Needs-Based Approach. The VA requested a methodology for deriving physician requirements to meet current and future “workload demands.” Not addressed directly is the issue of physician staffing required for the amounts and kinds of health care that veterans may “need,” however that term is defined. Nonetheless, the methodology could be readily adapted for this purpose.

• The Methodology Should Promote the Quality of Care. To develop a methodology that consciously promotes the delivery of high-quality medical care—perhaps the greatest challenge in the study—the committee has proposed a strategy in which expert clinical judgment plays a prominent role. Expert judgment is formally involved in the evaluation of statistical models for staffing, the independent derivation of physician staffing requirements, and in efforts to reconcile the estimates from these alternative approaches.

  The committee also advocates continued empirical investigation of the relationship between the intensity of physician care and patient outcomes. It demonstrates, by example, that as such linkages are established, it becomes possible to derive physician FTEE levels that are consistent with achieving certain designated quality-of-care standards.

• The Methodology Must Be Relevant to the Present, Flexible for the Future. The committee has assumed that health resource allocation in the VA will be centrally directed and locally executed—but it urges a strong, two-way dialogue between VA Central Office and the VAMCs. It is also assumed that, for the foreseeable future, the VA will continue to provide health care directly to veterans, on a large scale, primarily through its own network of hospitals, clinics, and nursing homes.

The committee did not analyze, however, the issue of determining the additional requirements for VA physicians in the event of a war or other national emergency. The data available to the committee, based on current VA patient care delivery, did not permit a sound empirical investigation. Nonetheless, the committee believes that a methodology structurally similar to the one proposed here could be applied successfully to a wartime caseload, though additional empirical analyses would be required to achieve this adjustment.

One assumption the committee did not make was that the VA health care system of the future would necessarily exhibit the same configuration of inpatient, ambulatory, and long-term care programs and services as presently seen. For the non-VA sector, there have been dramatic shifts from inpatient to alternative forms of care, particularly ambulatory and long-term care; primary care and prevention are being emphasized. The committee notes that similar pressures exist in the VA.

This is the major reason the methodology emphasizes that physician workload relationships should be analyzed (where feasible) at what is termed the patient care area (PCA) level, as well as at the facility level.¹

It is crucial that the methodology possess this degree of flexibility. With the size and age structure of the veteran population changing significantly, the VA health care system of the future may look quite different than the present one.

In designing a physician requirements methodology, however, it was not the committee's intent either to defend and preserve the status quo or to overturn it in favor of a newly configured VA system. Rather, the methodology should be seen as a vehicle for calculating physician requirements for whatever programs and services the VA determines to be appropriate. That is, the methodology is not a substitute for fundamental policy choice—it is a means for helping to implement those choices once management has determined the needs of the system.

The VA physician requirements methodology involves statistical formulas that use existing VA data. It involves methods for using expert judgment to derive appropriate physician staffing. It can accommodate physician staffing guidelines emerging from outside the VA health care system (external norms). Overall, however, the methodology is best characterized as a decision-making process—a process for using these approaches, in concert, to establish physician staffing recommendations that are defensible by definable criteria.

The analyses in chapter 4 of the report demonstrate how physician requirements can be derived from statistical models estimated from existing VA data. Specifically, the committee developed Empirically Based Physician Staffing Models (EBPSM) with two complementary variants: the production function (PF) model and the inverse production function (IPF) model. In chapter 5, two alternative expert judgment models for physician staffing were introduced—one based on the Detailed Staffing Exercise (DSE) and the other, on the Staffing Algorithm Development Instrument (SADI). A third general 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 PF is estimated statistically for each PCA at the VAMC.² Each model relates (PCA-specific) workload to a number of variables thought to influence productivity, including physician FTEE for direct care, by specialty. To derive the total physician FTEE in a given specialty (e.g., neurology) or clinical program (e.g., ambulatory care) required for patient care at a given VAMC, one must solve for the FTEE required to meet patient workload on each relevant PCA, then sum across PCAs.

In the IPF variant of the EBPSM, specialty-specific rather than PCA-specific models are estimated. Each model directly relates (specialty-specific) physician FTEE for patient care and resident education to a number of variables thought to influence physician requirements, including workload.³

Under either the PF or IPF variant, total FTEE required at the facility is the sum of the model-derived estimate plus separate estimates for those FTEE components, such as research and continuing education, not incorporated in the model.

A DSE and (subsequently) a SADI were developed for each specialty (e.g., medicine) or VA program area (e.g., ambulatory care) analyzed by the six specialty and two clinical program panels. Each DSE and SADI has two major sections. The first (section A) focuses on physician requirements for direct care and resident education in the PCAs of a VAMC. For each ward, clinic, and procedure, the expert is asked to assess the amount of physician time—in hours —required per day, per visit, or per unit, respectively, to produce good-quality care.

The second section (B) of each DSE and SADI contains questions about the amount of physician time required for night and weekend coverage in the PCAs, education activities not occurring in the PCAs, research, administration, other facility-related activities, and leaves of absence.

Time estimates for all patient care and non-patient-care activities are summed and converted to FTEE—assuming one FTEE translates into a 40-hour/week commitment.

As an overall framework for determining VA physician requirements (given workload and other factors), the committee endorses a Reconciliation Strategy in which the major components of physician FTEE are analyzed separately, then combined to produce the total FTEE required, by specialty or program, at the VAMC.

The three major components of physician FTEE are: (1) a large category (labeled simply “X” in the report) that includes all patient care, resident education, administration, and leaves of absence; (2) research; and (3) continuing education. Together, these components are intended to represent a mutually exclusive and exhaustive categorization of how a physician's time is allocated at a VAMC. To execute the Reconciliation Strategy, for a given specialty or program at a VAMC, is to determine for each physician FTEE component:

• the most appropriate empirically based estimate of FTEE,

• the most appropriate expert judgment-based (or, alternatively, external norm-based) estimate of FTEE, and

• the most appropriate relative weight accorded to each in a simple formula [see Equation 6.1 of the report] for deriving a recommended FTEE level for this component.

The calculations are repeated for each of the three FTEE components, the results are summed, and what emerges is total physician FTEE requirements for the specialty or program.

The specific configuration of the Reconciliation Strategy recommended by the committee conveys a particular policy perspective:

In determining physician requirements for each specialty or program area, the first step is to derive a “baseline” FTEE estimate from a variant of the EBPSM, either the IPF or the PF. The second step is to investigate whether this baseline should be modified by expert judgment in light of factors threatening the validity of the empirically based model.

It sometimes would not be practical for a VAMC to realize instantaneously the new “target” level of physician staffing in a given specialty or program that emerges from application of the Reconciliation Strategy. The committee recommends that when this is the case, the VA consider phasing in the target by establishing an intermediate target. These increments (or decrements) in staffing would provide 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.

Within the “umbrella” of the Reconciliation Strategy, how exactly should VA physician FTEE levels be calculated, by specialty and program area?

1. Physician FTEE for direct care, resident education, administration, and leaves—Based on the analyses summarized in chapters 4 through 7, the committee reached the following conclusions regarding approaches to analyzing this major component of physician FTEE:

• The PF and IPF are potentially complementary variants of the EBPSM, and either is a viable candidate for helping generate the empirically based estimates for this component of physician FTEE.

• To derive expert judgment FTEE estimates for use in the Reconciliation Strategy, the most promising approach is a methodology built around the SADI. The SADI permits physician requirements to be assessed in almost as much detail as the DSE, but with much greater efficiency; because the SADI is specialty- or program-specific, rather than VAMC-specific (like the DSE), it could be applied periodically across the VA system much more economically than the DSE.

  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.

• The relative weight accorded to empirically based versus expert judgment approaches in the Reconciliation Strategy should be determined on a facility-specific or facility-group basis.

2. 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. Possible indicators include the amount of VA and non-VA research funding, the quantity of peer-reviewed publications,

or (most simply) the amount of FTEE currently allocated by each specialty to “research” in the VA's Cost Distribution Report. In principle, the committee's preferred indicator is research funding.

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

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

Nonetheless, the committee believes that useful external norms can be developed. To accomplish this, a detailed examination of physician staffing levels in relation to workload and other factors affecting physician productivity would need to be undertaken at each non-VA facility selected for analysis. The committee recommends that the VA pursue these more detailed external norm analyses.

The primary purpose of the study has been to develop a physician staffing methodology. Physician requirements were computed selectively for specific specialties and sites, but this was always for demonstrating or testing a method or model. Hence, the committee concludes that:

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

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

In keeping with the report's focus on methodology rather than the adequacy of specific staffing levels, the committee acknowledges the panels' views but takes no formal position on their specific conclusions about the adequacy of current staffing. But these panel conclusions, emerging after months of careful deliberation, bear sufficient policy significance to warrant immediate investigation by the VA.

The proposed physician requirements methodology provides the means to do this.

By its very structure and logic, the Reconciliation Strategy implies that the allocation of physician FTEE across the system would be more centrally directed than is currently the case. Within each specialty or program area, all facilities would be judged by the same criteria. There is the presumption that facilities with similar mission-related demands would be prescribed similar physician FTEE levels.

For the Reconciliation Strategy to be implemented successfully and to be improved over time, there must be strong channels of communication between Central Office and each VAMC. And the dialogue must be an active, two-way interchange. The committee does believe that the physician staffing methodology would be more likely to influence VA physician staffing if the methodology were made an integral part of the budget process at the facility level. Therefore, the committee recommends that the VA undertake this integration concurrently with the implementation of the methodology. These analyses would be facilitated if the physician requirements methodology were a component part of a larger VA “decision support system” that promotes a comprehensive integration of resource planning and budgeting.

The committee's views about VA-medical school affiliation relationships, presented at length in chapter 9, can be summarized as follows:

• The overall impact of affiliations on the VA health care system is strongly positive. These benefits include an improved ability to attract and retain well-qualified physicians and other health professionals; 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, a mandated part of the VA's mission that cannot realistically take place currently in the absence of affiliations; and participation in medical and health services research, which benefits the general population as well as veterans.

• The VA should explore strategies for developing and expanding affiliations to include facilities that currently are not affiliated.

• 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.

Early in the study the committee hypothesized that VA physician requirements may be influenced by the availability of certain nonphysician practitioners (NPPs). In chapter 10 the committee presents recommendations on the present and future role of four types of NPPs: physician assistants, nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists.

• Both the procedures for collecting data at the VAMC and the format of the SADI should be revised so that the impact of NPPs on physician requirements can be determined with greater specificity than at present, using either the empirically based models or this expert judgment approach.

• Continuing education on the use of NPPs should be provided to VA physicians, and NPPs should receive continuing education to enhance their clinical skills. Wherever possible, the VA should establish academic affiliation relationships with NPP training programs to augment these education efforts.

• 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 allow the VAMC adequate flexibility for innovation and quality control.

• 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.

In chapter 11 the committee presents a number of recommendations for testing, refining, and extending its proposed methodology:

• Improve the EBPSM by increasing the accuracy of the data from the VA's Cost Distribution Report, developing new variables for the models, and periodically reestimating the models as factors influencing physician productivity—or its measurement—change over time.

• Evaluate and refine the SADI by applying the present instruments to all VAMCs, or at least a representative sample, and then revising each instrument accordingly.

• Pursue more detailed analyses of external physician staffing norms by studying in depth a selected number of non-VA clinical sites. The resulting (non-VA) physician task times could then be applied to workload data from a given VAMC to derive an implied total quantity of physician FTEE required.

• Extend current workload projection procedures to incorporate patient demand models, in which the veteran's predicted utilization of the VAMC becomes a function of income, health insurance coverage, and other factors affecting the propensity to select the VA system. The workload projection procedures used in the present study, adapted directly from existing VA models, produced facility- and PCA-specific utilization estimates adjusted only for the projected change in the age distribution of the veteran population.

• Pursue these improvements through a two-phase strategy; Phase I would involve an intensive two-year effort to accomplish the tasks just summarized, while Phase II represents an ongoing effort to reevaluate and possibly revise components of the methodology.

The committee's recommended methodology is multifaceted because no one approach to determining physician requirements is without its flaws. But when the approaches are considered in concert, the opportunity is created to bring the full range of relevant information to bear on the problem.

A useful by-product of the methodology is that it is possible to compare the actual and model-predicted performance of individual VAMCs in terms of physician staffing intensity and workload productivity.

If the VA adopts, and adapts as needed, the proposed methodology, the quality of its physician staffing decisions should improve over time—and so should the quality of VA health care.