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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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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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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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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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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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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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