SECTION II

AFFILIATIONS PANEL REPORT



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Physician Staffing for the VA: VOLUME II SECTION II AFFILIATIONS PANEL REPORT

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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 AFFILIATIONS PANEL REPORT Karl D.Yordy and Judith L.Teich INTRODUCTION As a part of the broader charge by the VA to the Institute of Medicine for the study of physician requirements, the study committee was charged with examining the impact on physician manpower requirements of “changes in the number, type, and intensity of VA-medical school affiliations.” The work plan for the study states: “There are two sorts of analyses essential to the development of a methodology for determining physician staffing requirements associated with the VA education/training mission. The first would be concerned with adjusting FTEE staffing requirements for patient care to take account of the loss of staff time for teaching students and the gain in patient care services provided by residents. The second would examine the broader implications for the VA health care system of its medical school affiliation agreements.” Early in the course of the project, the study committee determined that the first sort of affiliations analysis would be handled by the data and methodology panel as part of the empirically based physician staffing models being developed. The second type of analysis, involving the broader and more qualitative implications of affiliations, thus became the focus of the affiliations panel. The panel consisted of 11 members, 6 physicians not currently associated with the VA, appointed by the IOM, and 5 VA physicians. Five of the non-VA members were also members of the study committee, assuring a close linkage between the analyses and deliberations of the panel and the findings and recommendations of the study committee, as reflected in Chapter 9 of Volume I. The panel roster is attached.

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Physician Staffing for the VA: VOLUME II In carrying out its charge to develop a report on the implications of the affiliation arrangements for the VA health care system that would be useful to the study committee in its deliberation, the affiliations panel met five times to consider the issues and to review information gathered by the staff at the direction of the Panel. Because of the great variety among the affiliation arrangements and the lack of systematic data about the effects of these arrangements on physician staffing and other important medical care issues, generalizations are difficult. However, careful consideration of the information available to the panel from the sources mentioned above, along with the personal knowledge of the VA system represented on the panel, provided a basis for informed judgments by the Panel in providing advice and information to the parent study committee. Detailed, systematic empirical information about the effects of the affiliations would have required a much greater effort to gather data than the resources available to the Panel would permit. Important qualitative aspects of the effects may not lend themselves to empirical analysis until better information on the relationship between resource inputs and the outcomes of care become uniformly available for all VA facilities. Nonetheless, the Panel believes that their findings and conclusions are sound and provide useful material for consideration by the study committee. What is clear, in the Panel's judgment, is that the affiliation arrangements are integral to the effective functioning of the VA health care system at the current time, and that the overall effect of these arrangements on the recruitment and retention of highly qualified physicians and on the provision of many types of medical care has been beneficial. BACKGROUND AND HISTORY OF VA-MEDICAL SCHOOL AFFILIATIONS The principles and concepts regarding affiliation agreements between the VAMCs and U.S. medical schools have been in force for over 40 years. On January 3, 1946, President Harry S.Truman signed Public Law 79–293, establishing the Veterans Administration's Department of Medicine and Surgery (DM&S). Shortly thereafter, on January 30, 1946, the Chief Medical Director of the Veterans Administration published the second Policy Memorandum on the subject of the Department's policy in the association of veterans hospitals and medical schools (Worthen, 1987). The Veterans Administration had been established as an independent federal agency in 1930, combining the Bureau of Pensions (formed in 1833), the

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Physician Staffing for the VA: VOLUME II National Home for Disabled Volunteer Soldiers (1866), and the U.S. Veterans Bureau (1921). Following World War II, members of the medical community became alarmed at the number of returning servicemen filling VA hospital beds, particularly since civil service red tape, and the bad reputation of VA medical care had caused a critical shortage of doctors within the system. The creation at that time of a separate personnel system for the VA (Title 38) helped to circumvent some of the bureaucratic delays in hiring physicians. The idea of having the ranking medical school as medical affiliates of VA hospitals was implemented largely through the efforts of Dr. Paul Magnuson, an orthopedic surgeon from Northwestern University in Chicago, who came to Washington, D.C., to meet the challenge of upgrading veterans' medicine by forging such affiliations. Well known to many of the deans and university professors in medical schools across the country, Dr. Magnuson drafted a plan to have medical school deans supply the staff for the VA's hospitals, and determined that he could have the first two such affiliation agreements operational within six weeks. At that time, the VA had 83,339 beds in 98 hospitals, most in remote locations, such as Indian reservations. None of the hospitals had accredited residency programs; the 1,000-bed VA hospital in Palo Alto had only five doctors. The day after the signing of Public Law 79–293, 56 residents were placed at Hines General (VA) Hospital in Chicago, by Northwestern University and the University of Illinois. During the next three weeks, the University of Minnesota placed 26 residents at Fort Snelling; over the following months, Dr. Magnuson went to Boston, New York, San Francisco, and other major cities to enlist the aid of medical school deans in establishing affiliations. As outlined in Policy Memorandum No. 2, “The schools of medicine and other teaching centers are cooperating with the threefold purpose of giving the veteran the highest quality of medical care, of affording the medical veteran the opportunity for post-graduate study which he was compelled to forgo in serving his country, and of raising generally the standard of medical practice in the United States by the expression of facilities for graduate medication. The purpose of the Veterans' Administration is simple: affording the veteran a much higher standard of medical care than could be given him with a wholly full-time medical service.” The memorandum goes on to state that

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Physician Staffing for the VA: VOLUME II “The Veterans' Administration retains full responsibility for the care of patients, including professional treatment, and the school of medicine accepts responsibility for all graduate education and training” (Worthern, 1987). By 1950, the number of VA hospitals had increased to 151 centers with 117,000 beds. During the 1950s and 1960s, the total number of hospitals continued to increase; many outdated facilities were replaced, and new affiliations were established. A new policy in the late 1960s directed that new VA hospitals be built on or near campuses of affiliated medical schools. The VA Medical School Assistance and Health Manpower Training Act of 1972 provided for grants to assist in the establishment of new state medical schools that would be affiliated with VA medical centers. The Act further provided funds for medical schools already affiliated with VA hospitals, to enable them to expand significantly their collective class size and, in several cases, their curricula. RELATIONSHIP OF AFFILIATIONS TO PHYSICIAN REQUIREMENTS Currently, 134 of the 172 VA medical centers in the United States have some form of affiliation agreement with 102 of the 127 U.S. medical schools. These agreements represent a wide range with regard to the scope and intensity of the affiliations. Several of the facilities included among the “affiliated” group indicate only undergraduate medical student training, rather than the presence of residents; a number of others list several staff physicians who have faculty appointments at the affiliated medical school, but apparently train neither students nor residents within the VA hospital itself. At the other end of the continuum are the large, urban, tertiary care VAMCs, many of which train 100 or 150 residents in many different specialties, as well as large contingents of medical students on clerkships, and trainees in many other health professions. There are currently approximately 80 VAMCs with substantial affiliations comprising residents in a number of different specialties. Many questions arise in relation to the utilization and allocation of physicians and physician time in these differing kinds of facilities. How do the responsibilities of a VA staff physician in a small, rural, unaffiliated hospital differ from those of a VA staff physician in a highly affiliated, urban, tertiary care medical center? Do highly affiliated facilities need larger numbers of staff

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Physician Staffing for the VA: VOLUME II physicians because a higher percentage of their physicians' time is devoted to activities other than patient care, i.e., research, teaching, or administration? How does the presence of residents affect the amount of staff physicians' time that must be devoted to patient care—do residents make a significant contribution with regard to patient care, thereby reducing the time that staff physicians must spend, or does the amount of physician time necessary to train them more than offset the amount of patient care time which residents might contribute? Underlying these questions are other, more subtle issues regarding the ways in which affiliations affect physician staffing patterns. It appears, for example, that the more highly affiliated a VA hospital is, the more likely it is to employ large numbers of part-time rather than full-time staff physicians. Some VA medical centers employ almost no full-time staff physicians. What are the implications of such staffing arrangements? Do part-timers actually contribute the amount of time for which they are compensated? Could the needed amount of services be delivered efficiently in any other manner? Do these part-time arrangements have an impact on staff morale or loyalty? Further, can physician time be effectively monitored under such arrangements, so that the VA can be assured that it is “getting what it is paying for”? Another level of complexity related to the degree of affiliation is the fact that affiliated hospitals have access to a pool of physician manpower which is not captured in any date system nor accounted for in any formal manner. Many physicians who do not appear on the VA payroll at all may contribute time to patient care, teaching, and/or research at the VAMC as a result of the strength of a particular affiliation. Is there any way in which this “hidden” manpower contribution could or should be factored into the assessment of physician requirements of a particular VAMC? MAJOR ISSUES WITH REGARD TO VA-MEDICAL SCHOOL AFFILIATIONS These questions and others, were the starting point for the Panel 's deliberations. As the Panel's began its work, a number of major issues were defined: What do the VAMCs gain through the affiliation agreements? Do affiliation relationships represent an even exchange between VAMCs and medical schools? What impact does this allocation have on the numbers of physicians required in various facilities? How are physicians utilized in affiliated facilities?

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Physician Staffing for the VA: VOLUME II How do they allocate their time with respect to patient care, teaching, and patient care responsibilities? What would be the likely implications and consequences for the VA system if affiliations were to be curtailed or discontinued? What is the VA's primary mission, and how do affiliation relationships relate to it? Are unaffiliated hospitals (and/or services) perceived as “second-class citizens” in the VA system? If so, how can this be addressed? Each of these issues is discussed below. What do the VAMCs gain through the affiliation agreements? Do affiliation relationships represent an even exchange between VAMCs and medical schools? In recent years, there has been a sense on the part of some observers that medical schools may be “taking advantage” of the VA by expecting VA hospitals to provide teaching and supervision as well as substantial research space, which is difficult to find in the schools themselves. Further, some VA personnel express the fear that medical schools are usurping control of affiliated VA hospitals through the existence of Dean 's committees, and the influence which these committees may exert over hiring of VA staff physicians and over the day-to-day functioning of the hospitals. These concerns led to some of the central questions posed by the Affiliations Panel: to what extent is it possible to assess and evaluate the exchanges which take place in VA-medical school affiliation relationships? What benefits or value do medical school affiliation relationships provide to the VA? Ability to deliver tertiary care. The panel began with the observation that in the United States virtually all institutions delivering state-of-the-art tertiary medical care are teaching institutions with strong ties to medical schools. Therefore, the VA's access to state-of-the-art tertiary medical care is inextricably tied to affiliations. Affiliations allow the VA to participate in the way in which tertiary care is delivered to the United States, and allow the VA access to other institutions of the highest quality. Further, affiliations are cost-efficient; they allow the VA to benefit from resources which already exist for the provision of tertiary care, and enable the sharing of capabilities. To the

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Physician Staffing for the VA: VOLUME II extent that the VA intends to continue delivering tertiary care, affiliations appear to be a necessity unless very substantial resources are available. Ability to deliver high-quality care. The relationship of affiliations to improved quality of care was a theme woven throughout much of the Affiliations Panel's deliberations. However, while there is a widely held belief that affiliations result in a higher standard of medical care, it is extremely difficult to prove this empirically. Mortality statistics, accreditation rankings, levels of physician recruitment and retention, or percentages of physicians who are board certified have all been suggested as inferential measures of quality, but are currently viewed as inadequate indicators primarily because the link in the full range of desired outcomes of care has not been established. Affiliations Panel staff explored current literature on a number of these measures, as well as the availability of such data within the VA system. The panel determined that it would be of great benefit to the VA to be able to conduct analyses related to medical care outcomes, although data collected currently by the VA may not be adequate to do so. The development of quality indicators is still in its early stages in the private sector. The panel recommended that the ongoing private sector research efforts in this area be carefully monitored by the VA, and VA data collection improved, so that appropriate studies of quality of care may be carried out by the VA in the future. Increased access to well-trained physicians. Primarily as a consequence of the affiliation agreements, physician staffing in many VAMCs is supplemented by faculty from the medical school, who provide services under the headings of “Consulting and Attendings” (C&As) and “Without Compensation” (WOC). C&A physicians earn a flat fee of $45.00 or $75.00, depending on seniority and academic rank, regardless of the duration of their visit to the VAMC. WOC physicians also provide both patient care and teaching/supervision services to VAMCs, for which they are not compensated at all. Data on the time spent and services contributed to VAMCs in this manner are not kept systematically, either at the facilities or in any centralized database. In order to estimate the magnitude of physician effort which these arrangements represent to the VA system, the Affiliations Panel conducted a series of four site visits in November 1989, and a mail survey of 24 VAMCs in February 1990, to help clarify the contribution of C&A and WOC physicians.

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Physician Staffing for the VA: VOLUME II The presence of C&As and WOCs appears to bear a direct relationship to the degree of affiliation in any given VAMC. Four large, highly affiliated facilities were visited. Discussions with chiefs of staff, directors, and service chiefs at these four hospitals suggested that a careful accounting of time actually contributed by C&A and WOC physicians (some of which has to be estimated, since in many instances there are no written records kept of time spent at the VA) yields a relatively small number of physicians per month, approximately 2 to 3 FTEEs in the VAMCs visited. There are often large numbers of physicians whose names appear on the lists of C&As and WOCs, and a relatively large number of individuals involved in such activities at a particular VAMC; however, most of these individual physicians may come to the VA only once or twice a month, for an hour or two at a time, and much of their time may be spent in teaching or supervising residents. Therefore, when C&A and WOC time is translated into FTEE, the results seem disproportionately small; even the largest and most highly affiliated facility of those visited showed a total of 3.0 C&A and WOC FTEE per month for the entire VAMC. The significance of the contribution of these C&A and WOC physicians should not, however, be underestimated; most often, they represent highly skilled subspecialists to which the VAMC has access only through this arrangement. Their presence in the VAMC is of vital importance to VA staff physicians with respect to staff morale, as well as access to “state-of-the-art” medical expertise and technology. The significance of their presence in affiliated VAMCs is thus much greater than the 2.0 or 3.0 FTEEs per month which their actual collective hours might suggest. The following “Issues for Consideration” regarding WOC and C&A physicians emerged from Affiliations Panel site visits to the four VAMCs: Consultant and attending visits and expenditures are generally monitored through the office of the Chief of Staff. C&A FTEE can be estimated by making assumptions regarding average amounts of time per visit; these apparently vary significantly by specialty (for example, some WOCs and C&As may perform surgical procedures at the VA which take six or eight hours.) Service chiefs stated that C&A/WOC time is most often spent in direct patient care, e.g., performing surgical procedures, but that this patient care always takes place in the presence of trainees (residents and/or students), and therefore may also be regarded as teaching. Further, there are some C&As/WOCs who do only didactic teaching—rounds, lectures, supervision, i.e., related to specific patients but not necessarily “hands-on teaching,” nor in the presence of the patient.

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Physician Staffing for the VA: VOLUME II It had been reported that, at some highly affiliated VAMCs, physician resources may be as much as 30 percent higher than what is shown on the organizational chart. One service chief referred to this as the difference between the VAMC's organizational chart and the “real” one. The chief of surgery at one VAMC estimated that between 40 and 50 percent of the surgical procedures at his facility are supervised or performed by WOCs; it was estimated at another VAMC that 40 percent of the patient care time in medicine and its subspecialties is being contributed by WOCs. For example, at this VAMC there is only one dermatologist on staff, but there are five WOC dermatologists, who help to cover the four clinics each week. It is difficult, however, to reconcile these statements with the relatively low results of C&A and WOC FTEE which resulted from the calculations done with the chiefs of service and their administrative assistants, as well as the data gathered from the survey questionnaires. One possible explanation is that the time of C&As and WOCs represents only clinical (patient care and teaching) time; that is, it does not take into consideration that issue of non-patient care time (research, administration, leave, etc.) that the statistical model and the staffing exercises developed in this study attempt to build into FTEE for staffing physicians. If one were to use only the clinical portion of a staff MD FTEE as a basis for calculating C&A and WOC FTEE, the result would probably be an FTEE calculated on the basis of 25 or 30 hours, rather than 40. In considering the above estimates of C &A and WOC time, it should be noted that a 40-hour FTEE was used, which may have resulted in some underestimation. A modification of this sort in calculating FTEE for WOCs and C&As might, in fact, yield a more accurate representation of the amount and proportion of time which they contribute. It was noted that there are many consultants who participate in coverage schedules, but who are not paid unless there is an emergency for which they actually physically come into the hospital. In that case, it would be counted as a C&A visit; however, the fact that they provide coverage on a routine basis is not indicated nor captured in any data system. Involvement of C&As and WOCs appears to differ by specialty in the VAMCs visited. It appears that both WOC physicians and C&As are less of a factor in psychiatry than in medicine and surgery; all four hospitals visited (in 1989) reported using very few WOC/C&A physicians in psychiatry. This may be related to the fact that all of these VAMCs have relatively few residents in psychiatry (ranging from 4 to 14). Other factors contributing to the difference between specialties in C&A and WOC use probably relate to the nature of physician-patient interaction in different specialties, and the possible

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Physician Staffing for the VA: VOLUME II question whether teaching hospitals are, in fact, worth the increased cost, and whether federal programs have an obligation to subsidize graduate medical education. In this climate of growing skepticism regarding the practice of medicine and medical care costs, and a questioning of public responsibilities, it is not surprising that within the VA, the network of teaching hospitals should be perceived as a possible cost-containment target, and that the relationships between these VA hospitals and medical schools should come under scrutiny. Why do teaching hospitals incur higher costs? A 1989 monograph published by the Council of Teaching Hospitals (COTH) of the Association of American Medical Colleges examines the distinctive organizational and service characteristics of major teaching hospitals (Association of American Medical Colleges, 1989). It states that the member hospitals of COTH are significantly larger than other hospitals; half of COTH hospitals have over 500 beds, while half of nonteaching hospitals have 99 beds or less. Nearly two-thirds of COTH hospitals are located in metropolitan areas having a population of at least a million or more; over half of nonteaching hospitals are located in rural areas. It is significant to note that COTH-member teaching hospitals are the major providers of specialized, tertiary care services. For example, 55 percent of all organ transplant capabilities, 51 percent of all hospital-based genetic screening and counseling units, and 29 percent of hospital-based NMR imaging facilities are in COTH hospitals. This COTH publication points out that the addition of the educational role involves extra costs to teaching hospitals for supervising faculty, clerical support, physical facilities, lowered productivity, and increased use of ancillary services. However, because patient care and clinical education cannot be clearly separated, it is difficult to identify distinctly many of the educational costs. Even after accounting for educational and research costs to the extent possible, care in teaching hospitals is still more expensive than care in nonteaching hospitals. This is due to factors relating to the types of patients cared for in teaching hospitals, and the environment in which teaching hospitals are located. In the VA, as in the private sector, highly sophisticated, expensive tertiary care programs serving the entire community and the regional area are located in affiliated teaching hospitals. Consequently, patients with the most difficult diagnoses and needing the most complicated treatments—the most expensive patients—are typically referred to and cared for in teaching hospitals. Further, the geographic environment in which most major teaching hospitals are located—large urban centers—adds to their operating costs; teaching hospitals must pay more for such items as labor and supplies. Because many teaching hospitals employ large numbers of staff physicians for administration, teaching,

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Physician Staffing for the VA: VOLUME II and unit supervision, teaching hospital costs often include some physician costs for services not included in the costs of nonteaching hospitals. What would be the likely implications and consequences for the VA system if affiliations were to be curtailed or discontinued? As outlined in the study work plan, part of the Affiliations Panel 's responsibility was to address the question of “disaffiliation” and its potential impact on individual VAMCs and on the VA system as a whole. However, there have been no instances in which an entire VA facility has lost or terminated its affiliation; therefore, this situation could not be studied empirically. The panel decided that a series of site visits exploring the views of VA staff physicians regarding “disaffiliation” would be the best way to approach the issue; the question was explored during the interviews during the final eight VAMC site visits. Clearly, there is widespread concern among VA staff that any changes which curtail or eliminate affiliation relationships would result in serious negative consequences for affiliated VAMCs, as well as for the nation's medical schools. What would be these likely consequences for the various affiliated VAMCS and their services if affiliations with medical schools were to be restricted or discontinued? When this question was posed during the site visit interviews, the most frequent responses were “It would be a complete disaster,” “I wouldn't be here,” or “Ninety percent of the staff would leave within six months.” Many staff physicians replied that the quality of care in the VA would deteriorate, that the VAMCs would be unable to sustain any research programs, and that the quality of physicians attracted to working in the VA would decline. The most obvious consequence of “disaffiliation” would be the loss of residency training in the VA; there are virtually no ACGME-accredited residency training programs in the United States which are not medical-school affiliated. The restricted nature of the VA patient population renders it virtually impossible to give residents the necessary range of exposure and experience required by the accrediting council, unless they have the opportunity to rotate through other hospitals. The loss of medical school and residency training was viewed as having a serious negative effect on morale and on retention and recruitment of physicians; almost all of those interviewed stated that the presence of students and trainees provides a stimulating and challenging environment which is vital to their interest in remaining at the VA. The

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Physician Staffing for the VA: VOLUME II importance of the teaching component is such that most of these staff physicians could not imagine wanting to remain in an environment without it. The interviewees generally agreed that if affiliations were curtailed, recruitment and retention of physicians would be negatively affected. Affiliation with a medical school, because of the stimulation inherent in resident and medical school teaching and in research activities, is a major factor in attracting highly qualified physicians to work at the VA. Affiliations may offset, to some degree, the fact that physician salaries in the VA tend to be lower than those in the community. Affiliations facilitate the involvement of consulting and attending physicians (C&As) as well as MDs who serve at the VA without compensation (WOCs). This contribution is seen as part of the overall affiliation agreement, and often represents an important range of physician services which would not otherwise be available to VA patients; if it were to be discontinued, quality of care would undoubtedly be negatively affected. A number of those interviewed pointed out the more “hidden ” aspects of the affiliation relationship: VA staff physicians have access to a wide range of resources at the medical school, such as medical libraries, which contribute significantly to their ability to stay current with developments in their fields. It was frequently stated that VAMCs would not be able to deliver the same level and range of acute tertiary care services which they now provide if they did not have medical school affiliations. Over time, facilities would probably be limited to care for chronic patients. A number of those interviewed immediately suggested the scenario that the VA would revert to its “pre-World War II condition” of providing only low-level, “custodial” patient care. Economic implications of disaffiliation. The recent New York State regulations regarding limitations on the scheduling of residents' time resulted in varying estimates of the costs of replacing the services rendered by residents which would be lost as a result of those regulations. It has been suggested that if the VA were to curtail or discontinue its affiliations, the loss of the residency training programs would similarly have serious economic implications for VAMCs, which would have to hire additional staff physicians to provide the services currently being provided by residents. The affiliations panel examined data from several studies regarding replacement of residents' services. The development and implementation of the statistical model proposed in this study would make possible in the future detailed analyses of the costs of replacing the service of residents, under varying assumptions regarding the proportion of residency programs which would be affected, the relative amounts that residents

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Physician Staffing for the VA: VOLUME II in various postgraduate years of training actually contribute to patient care, and so on. This is an issue which clearly bears further scrutiny within the VA system, and the panel recommends that the VA undertake such further analyses. Further analyses could also be directed at the costs of obtaining the services of medical specialists such as radiologists, anesthesiologists, and cardiac surgeons—hose compensation in the private sector is far above va compensation. What is the VA's primary mission, and how do affiliation relationships relate to it? Are unaffiliated hospitals (and/or services) perceived as “second-class citizens” in the VA system? If so, how can this be addressed? There is substantial discussion at the present time regarding the primary medical care mission of the VA health care system. Is the major responsibility of the system to provide comprehensive primary care, specialized tertiary care, long-term care, chronic care, or all of these? And to whom? As the veteran population ages and resources become more scarce, which of these missions should take precedence? Historically, affiliations have been concentrated in institutions which provide specialized, tertiary care; the VA's own projections, however, indicate that the need for short-term, acute tertiary care beds will decrease over the next few decades, while needs for long-term and chronic care will increase. Furthermore, if the eligibility of the veteran population is more narrowly defined to restrict health services that are nonservice connected, the spectrum of individuals and illnesses will be increasingly limited and probably will focus more on the chronically ill and mentally disturbed. How should resources be redistributed to reflect this change, and how might this redistribution affect existing VA-medical school affiliations? Within the VA system, there has been heightened competition in recent years for what are perceived to be increasingly scarce economic resources. There are also reports of a growing feeling on the part of the unaffiliated hospitals that they are being treated as “second-class citizens.” Chiefs of staff at these VAMCs maintain that their facilities are not sufficiently staffed, and that the VA's method of resource allocation does not adequately reflect their needs, favoring instead the already “well-endowed” affiliated institutions. Staff in unaffiliated facilities claim that they are not accorded the same status as their peers in affiliated facilities. However, there is also reported to be increasing recognition of the positive value of and potential for new directions in affiliations, especially on the part of

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Physician Staffing for the VA: VOLUME II unaffiliated hospitals. Possibilities for the new affiliation relationships involving both larger and smaller VA facilities are increasing, and this is generally seen as a positive trend, which is likely to upgrade patient care in those facilities. Consortia of hospitals, involving a medical school, a tertiary VAMC, and one or more smaller, less specialized VAMCs in the same geographic area—such as Mt. Sinai School of Medicine's arrangement with Bronx, Montrose, and Castle Point VAMCs—are indicative of this trend. There appears to be growing recognition that affiliations have benefits for these smaller, non-tertiary care facilities—benefits which include the attraction and retention of more highly trained staff, as well as improved morale and increased intellectual stimulation. Further, some academic centers are interested in the patient pool served by some unaffiliated primary care VAMCs; relationships between these two types of facilities thus may be beneficial to both parties. Some panel members pointed out that even in the most highly affiliated institutions, there are some subgroups which are not affiliated, especially in ambulatory care. There is a perceptible difference in the training and attitudes of physicians on these services, e.g., between the primary and specialized ambulatory services. As the need for ambulatory and chronic care services grows, attention is increasingly being focused on the need for residency education in these settings. Expanding VA-medical school affiliations to include these types of services and facilities may prove to be vital to the VA's ability to provide high-quality patient care to the veteran population. Through its affiliations, the VA has contributed to existing knowledge and quality of patient care in both long-term and ambulatory care services; tertiary care settings have been instrumental in facilitating these advances. The interrelationships and interdependences among services were mentioned as important features of affiliation: services may need one another in order to be accredited, as in the case of surgery and radiology. CONCLUSIONS AND RECOMMENDATIONS Conclusions For purposes of this study, the network of affiliation relationships between VA hospitals and medical schools has been considered from two perspectives: first, their relationship to physician requirements within VA facilities; and second, their overall impact on the VA health care system.

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Physician Staffing for the VA: VOLUME II Affiliations and physician requirements. The first perspective involves a number of concerns, such as the overall net productivity impact of residents in affiliated facilities. Detailed data on numbers of residents by specialty and by postgraduate year of training in every affiliated VAMC were obtained by the affiliations panel during the course of the study. These data had not previously been available on computer; by automating the data, study staff were able to integrate and utilize it in the staffing models which were developed by the data and methodology panel. This enabled empirical analysis, for the first time, of the extent to which the presence of residents influences workload production in a particular patient care area. Further, with regard to the impact of affiliations on physician requirements, the affiliations panel's exploration of the utilization of C&A and WOC physicians provides new data on this relatively “hidden” source of physician manpower. Analysis of these data strongly suggests that the contribution of C&As and WOCs is greater than the relatively modest amount of cumulative FTEE would suggest. C&As and WOCs apparently bring a range of subspecialty training and expertise to the VA which otherwise would not be obtainable, and serve other important functions in sustaining VA staff morale and providing stimulation. Similarly, the Affiliations Panel's examination of the use of part-time physicians indicates that their presence is highly correlated with the degree of affiliation in a particular VAMC. Employing part-time physicians with varying “eighths ” appears to allow the VA the flexibility to assemble a mix of subspecialists appropriate to meet patient demand, e.g., in the surgical subspecialties. This appears to be a cost-efficient method of providing these services. The affiliations panel's exploration of this issue also suggests strongly that, on balance, the “eighths” are an accurate reflection of the amount of time which physicians devote to the VAMC. Overall impact of affiliations on the VA health care system. Data and impressions gathered during numerous site visits by the affiliations panel indicate that the benefits of affiliation are generally perceived as: Improved ability to attract and retain well-qualified physicians; ability to provide state-of-the-art tertiary care; increased access to a wide spectrum of services and a pool of highly qualified physicians, as well as to other, “hidden” resources of the medical schools;

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Physician Staffing for the VA: VOLUME II ability to participate in the education of physicians, which is a mandated part of the VA's mission, and which cannot realistically take place currently in the absence of affiliations; participation in medical and health services research, and ability to contribute to the advancement of medical knowledge; and societal benefits related to all of the above. Underlying all of the above factors is the assumption that affiliations contribute strongly to improved quality of patient care. There are many inferential indications that this is true, although with existing data it is still difficult to substantiate this assumption empirically. More sophisticated outcome-related measures of quality of care are still in the early stages of their development, and the data to enable certain analyses of quality within the VA system are only partially available at the present time. It should be noted, however, that a number of potential quality indicators are currently being developed by the VA Office of Quality Management and other VA policy and management offices, and may be accessible in the near future. These data include: Records of recruitment and retention of physicians; Detailed information on board eligibility and board certification of physicians in all facilities; An extensive matrix of quality measures and scores utilized by the Joint Commission on Accreditation of Healthcare Organizations in its accrediting process; and Data from the Clinical Inventory survey of all facilities, which has recently been conducted by the VA Central Office. It is, therefore, possible that some empirical analyses exploring the relationship of affiliations to quality of care will be possible quite soon. Preliminary analysis of the net economic costs of affiliation—including, for example, the costs of replacing residents with other health care personnel—may also be available in the near future. Recommendations The Panel recognizes the significant value of the affiliation agreements to the VA health care system, and strongly recommends that these

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Physician Staffing for the VA: VOLUME II relationships continue to be supported and nurtured. The panel emphasizes the need to monitor the mutual benefits of affiliations to the medical schools as well as to the VA; both sets of institutions must have concrete positive reasons for continuing the arrangements. The panel recommends that the VA explore strategies for developing and expanding affiliations to include facilities which are currently not affiliated. Clearly, such arrangements would have to be tailored to the size of the facility and the scope of services offered, as well as to other particular attributes. Such an expansion of affiliations would promote and encourage quality assurance across the full range of VA facilities. The panel recommends that, while maintaining and promoting the tertiary care model of affiliations in VAMCs where it is appropriate, the VA should also work to develop new and innovative models of affiliation, targeted specifically to long-term care, ambulatory care, and rehabilitation. The Geriatric Research, Education, and Clinical Centers provide one such successful model, which might serve as an example for other such programs. The panel recommends that the VA continue to monitor developments in the private sector with regard to reliable and valid quality of care indicators; further, the panel encourages the VA to continue in its attempts to develop data which would enable it to utilize similar measures assessing and monitoring quality of care in its own institutions. Flexibility must be an important feature of affiliations; the future of these arrangements may depend on consideration of such factors as: changes in the population using the VA; changes in medical practice which affect the institutions and the mix of services which they provide, e.g., increasing emphasis on geriatrics, long-term care, and ambulatory care; and changes in patterns and norms regarding medical education. Affiliation relationships must be sufficiently flexible and dynamic to accommodate these kinds of changes if they are to flourish in the future.

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Physician Staffing for the VA: VOLUME II REFERENCES Association of American Medical Colleges. 1989. Teaching Hospitals: Multiple Roles, Distinctive Characteristics. J.Chusid and R.G.Petersdorf (eds.) Worthen, D. 1987. The affiliation partnership between U.S. medical schools and the Veterans Administration. Alabama Journal of Medical Sciences 24:83– 88.

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Physician Staffing for the VA: VOLUME II APPENDIX INSTITUTE OF MEDICINE Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements Survey of WOC Physician Time December 1989 Name of VAMC:_____________ Station Number:__________ Affiliated Medical School(s):___________________ Service: _____________ Section:_______________ ********************************************************* Please list below the total number of the following for WOC (Without Compensation) attending physicians on your service or section: Number of WOC visits to VAMC/month (for patient care conferences, teaching rounds, clinics, etc.): _____ Average number of hours per WOC visit: _____ Estimated number of WOC FTEE on your service per month (derived from questions 1 and 2 above): _____ Estimated number of patients seen per month at VAMC by WOCs: inpatients _______ outpatients ______ For surgical specialties, number of operations supervised and/or performed by WOC attendings in the OR per month: inpatients ______ outpatients (ambulatory surgery) _______ If VAMC has an off-site clinic: number of WOC visits to off-site clinic: _____ number of patients seen: _____ number of surgical procedures supervised or performed: _____

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Physician Staffing for the VA: VOLUME II INSTITUTE OF MEDICINE Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements AFFILIATIONS PANEL ROSTER W.EUGENE MAYBERRY (Chair),*† Chairman, Board of Development, Mayo Foundation, Rochester, Minnesota ERNEST M.BARSAMIAN, Chief of Staff, Brockton/West Roxbury VA Medical Center, Brockton, Massachusetts 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 DAPHNE K.HARE, Director, Medical/Dental Education Programs Service, Department of Veterans Affairs, Washington, D.C. ROBERT J.JOYNT,*† Vice President and Vice Provost for Health Affairs, University of Rochester, Rochester, New York LOUIS J.KETTEL,‡ Associate Vice President for Academic Affairs, Association of American Medical Colleges, Washington, D.C. DAVID H.LAW, Deputy Associate Deputy Chief Medical Director for Hospital Based Services, Department of Veterans Affairs, Washington, D.C. SAVITA PURI, Chief of Staff, Batavia VA Medical Center, Batavia, New York KARL E.SUSSMAN, Associate Chief of Staff for Research and Development, Denver VA Medical Center, Denver, Colorado Staff: Judith L.Teich, Staff Officer *Institute of Medicine member. †Study committee member. ‡Deceased November 1991.