Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Medicine Panel Report
Medicine Panel Report
Pages 75-98
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From page 75... ...
that demonstrate, by numerical example, how the expert judgment procedures developed by the study committee can be used to estimate physician requirements. Because these exhibits pertain specifically to medicine, they will be referenced in the course of this panel report; but since they immediately precede this report, they will not be repeated below.
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From page 76... ...
A staffing instrument developed for this initial meeting elicited a great deal of discussion regarding He shared assumptions necessary for an expert group to render reasonable judgments about physician staffing. After this first meeting, the panel concluded that study staff should pry filer with Be expert judgment process.
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From page 77... ...
Dunag the first meeting, the panelists were also introduced to a number of alternative specifications of the empirically based physician staffing model, including the data components collected by VA Central Office. At the conclusion of the first round of the eight specialty and clinical program panel meetings, the study committee, the data and methodology panel, and the VA liaison committee convened in May 1990 for a major strategy session, later termed Joint Meeting I
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From page 78... ...
At the second panel meeting, these DSEs were discussed thoroughly to determine whether panelists were using the same assumptions and to allow members to discuss the underlying reasoning behind their calculations. Following this, the panel was asked to reassess physician requirements in medicine at VAMCs I and II, again working independently.
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From page 79... ...
To derive physician requirements for a given VAMC, He estimated physician hours for patient care and non-patient care activities are summed, then converted to t-1 BE under the assumption that 40 work hours per week translate into one THEE. (Obviously, if this 4~hour-per-we~k equivalency assumption is replaced by one reflecting the average workwesl~ of VA staff physicians, the SADI~erived P-1EE estimates would change accordingly; this is true also for the DSE estimates.)
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From page 80... ...
EMPIRICALLY BASED APPROACHES TO DETERMINING PHYSICIAN SIAFfING IN MEDICINE In its two meetings and a subsequent conference call, the panel evaluated alternative specifications of the empirically based physician staffing models (EBPSM) that pertained e~cpre~ly to internal medicine.
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From page 81... ...
This allows for a more detailed consideration of how the structure and mission of the facility influence physician requirements. The panel is well aware that inaccuracies in Me VA's cost distribution report, particularly related to the allocation of physician P-1 EE across activities, have the potential to compromise the validity of the empirically based approaches.
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From page 82... ...
health care organizations in order to Seine the implications of productivity performance norms that may exist in the public and private sectors for appropriate physician staffing in He VA. Initially, the study staff also obtained some ~internal.
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From page 83... ...
This allowed computation of an P~lEE-workload relationship that was similar, in concept, to that derivable from VA data. Finally, physician staffing and workload data were available from a large nationwide HMO.
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From page 84... ...
CONCLUSIONS For determining VA physician requirements in internal medicine, the panel endorses a variant of Me study committee's Reconciliation Strategy that puts primary weight on Data driven. approaches to calculating t-1EE.
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From page 85... ...
The panel believes that expert judgment approaches for determining physician requirements are also valid, but, compared with statistically based approaches, they are relatively expensive and cumbersome to operate. Because the panel concludes that the PF model represents a satisfactory approach for determining internal medicine requirements given current VA staffing arrangements it sees no need to utilize either the SADI or the DSE as primary tools for calculating F1EE for medicine.
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From page 86... ...
Leaves of Absence The percentage of total t-1 HE earmarked for vacation, sick leave, administrative leave, and other authorized absences should follow established VA rules. ~has" Coverage for Nights and Weekends Assuming an adequate availability of residents, none is required.
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From page 87... ...
Overall Adequacy of Physician Staffing in the VA With a Ample of but three VAMCs examined in detail, the panel feels that it is not possible to produce a defensible quantitative assessment of whether the VA is understaffed or overstaffed in internal medicine. However, the panel's endorsement of an EBPSM, with its concomitant reliance on input-output data from the current system, followed from the observation that expert judgment estimates, although in general slightly higher than numbers derived from the empirical models, were in actuality quite close.
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From page 88... ...
In this regard, the panel urges the VA to continue efforts to improve the accuracy of the [-IiiE data in the Cost Distribution Report. Final Remarks For determining VA physician requirements in internal medicine, Me medicine panel endorses a variant of the Reconciliation Strategy that relies upon the PF for deriving t-1 EE for patient care, resident education, and administration.
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From page 89... ...
To provide a context for the response, each panel member was presented a summary of the physician Al ~E! level at the facility emerging, alternatively, Cam the CDR, Tom both empirically based approaches (as applicable, and from both expert judgment approaches.
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From page 90... ...
from the medicine service allocated to direct care in the inpatient medicine PCA; variable testing for a nonlinear relationship between VA staff internist ~ l ~E! and workload productionspecifically, that there are diminishing marginal returns to increases in internist ~ l FEE; VA staff physician P-lEE from surgery allocated to direct care in the inpatient PCA; VA staff physician -WE from psychiatry allocated to direct care in this PCA;
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From page 91... ...
; (MED MD x FELLOWS) = interaction term for the joint influence of VA staff internists and medicine fellows on the rate of workload production in this PCA; and N = number of inpatient medicine PCAs (equivalent to the number of VA medicine services)
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From page 92... ...
B Averse Production Function Medicine MElD MD = 1.234 + 3.982 MEDWWU + 0.00078 MEDCAPWWU (3.844;)
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From page 93... ...
allocated to resident training across ~ PCAs, plus 1; MEDWWU = toted medicine WWUs produced dunag the fiscal year in the inpatient PCAs of medicine, surgery, psychiatry, neurology, and rehabilitation medicine (divided by 10,000~; ME! DCAPWWU = total CAPWWUs produced during the fiscal year in the ambulatory PCAs of medicine and other physician services (divided by 10,0001; MEDRUGWWU = total RUGWWUs produced during the fiscal year in the long term-care PCAs of nursing home and intermediate care (divided by 10,000~; ALLOWS = total V1~E of medicine residents PGY4 and above at the VAMC; HGROUP2 = categorical variable assuming a value of 1 if the facility is in RAM Group 2 (small, general unaffiliated VAMC)
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From page 94... ...
94 TABLE 3 External Norms Medicine PilYSl~UN SI,IFP7NG FOR TIlE VA-VOLUME 1! Source, Result, and Derivation, if any: VA 2 MD + 1 MD/15 short-term beds + 1 MD/25 long-term beds Indian Health Service 1 MD + 1 MD/12 ADC 1 MD/5,000 visits American Medical Association Core Survey Disl = 4.8 dis/week x 47.9 week/year x (40 hour/week / 60.1 hour/week)
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From page 95... ...
MEDICINE PANEL REPORT TABLE 3 Extends Norms Medicine (continued) 95 NYH&HC ADC= ADC/attendings= Amb= visits/at/endings= Group Health ldc.
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From page 96... ...
96 P~lYSlCUN SI~FFlNG FOR TRE Vie-VOLUME TABLE 4 Application of the Staffing Norms to Three VAMCs Each of He available physician staffing norms discussed in the text was applied, in turn, to He three VAMCs studied in the second panel meeting in order to derive He number of physicians requited in internal medicine (as implied by each norm)
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From page 97... ...
JOHN G DEMAKIS, Director, Health Services Research, and Associate Chief of Staff, Hines VA Medical Center, Chicago, Illinois WILLIAM F
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