By Sandra Basu
WASHINGTON – Under pressure to develop an accurate method of assessing physician output and determining appropriate staffing levels at medical facilities, the VA has agreed to establish productivity models for five additional specialties by the end of this fiscal year.
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The agency continues to grapple, however, over what model produces the most reliable data.
The dilemma is far from new. Legislators pointed out at a recent hearing that the issue has been around for more than 30 years. Yet, a VA Inspectors General report late last year concluded that VA lacks an effective methodology to ensure appropriate staff to provide care for patients.
In 1981, the then-General Accounting Office (now Government Accountability Office) first recommended that VHA develop a system to measure physician productivity.
“Thirty-two years later, alarmingly little progress has been made and our veterans are the ones who suffer from it,” said VA Subcommittee on Health Chairman Rep. Dan Benishek (R-MI).
Subcommittee ranking Democrat Rep. Julia Brownley of California also emphasized the need for such plans.
“I understand that the wide range of specialties VHA offers varies in complexity and that it is often difficult to quantify the work that specialists provide day in and day out,” she said. “However, in a system with over 152 medical centers and nearly 1,400 community-based outpatient clinics, it is vital that VHA is able to establish a staffing methodology to help evaluate productivity, identify best practices within specialties, and develop staffing plans in order to properly manage resources.”
Madhulika Agarwal, MD, MPH, VHA deputy undersecretary for Health for Policy and Services, told the subcommittee in written testimony that VHA “is committed to establishing appropriate productivity models for five additional specialties by the close of this fiscal year.”
She added, “Over the next three years, we will refine and develop additional models that are individualized for specialty care,” she said.
Some Productivity Standards
Linda Halliday, assistant inspector general for Audits and Evaluations in VA’s Office of the IG, told the subcommittee that, while VHA has set productivity standards for radiology and ophthalmology, it has not established productivity standards for all specialties because of indecision on how to measure physician productivity.
“Generally, our audit results found that there is a consensus among VHA officials that VHA needs to develop a methodology to measure productivity; however, a lack of agreement exists within VA on the methodology to actually use,” she explained.
The lack of agreement is over the use of a productivity-based model for specialty-care services using the Relative Value Unit (RVU) measure, a comparable service measure to permit comparison of the amounts of resources required to perform various services within a single department or between departments. Weight is assigned to such factors as personnel time, level of skill and sophistication of equipment required to render patient services.
Halliday said, while some VHA officials consider the RVU-based productivity model inadequate as a standalone measure for staffing, other VHA senior officials argue the RVU model is the best method currently available.
In the meantime, Halliday said the lack of productivity standards limit “the medical center’s ability to determine the appropriate number of specialty physicians needed to meet patient-care needs.”
Using a rudimentary measurement of physician specialty productivity, the IG analyzed the collective group of specialty physicians at all medical facilities. Halliday said it determined that 12% (824 of 7,011) of physician full-time equivalents (FTEs) did not perform to the standard.
“The 824 physician FTEs represented approximately $221 million in physician salaries during fiscal year 2011,” she said in written testimony. “Although we did not analyze the productivity of individual physicians, our results support the need for an in-depth evaluation of staffing.”
The IG also compared the staffing levels with the amount of work performed by eight specialty-care services at five medical facilities. Specifically, Halliday, said the analysis analyzed the workload output per clinical FTE for each specialty-care service and found significant differences in workload.
“One medical facility classified as ‘1a’ had 0.8 FTE providing endocrinology care to 1,053 unique patients for a total of 1,627 encounters,” she said in written testimony. “During the same period, a medical facility also classified as ‘1a’ had 0.4 FTE that provided endocrinology care to 1,347 unique patients for a total of 2,286 encounters. Although the latter medical facility had about 50% less dedicated FTE, the medical facility provided 41% more encounters.”
The IG recommended VA establish productivity standards for at least five specialty-care services by the end of FY 2013 and approve a plan that ensures all specialty-care services have productivity standards within three years, Halliday said. The report also recommended that the VA provide medical facility management with specific guidance on development and annual review of staffing plans.
Tools Being Created
The VA has taken steps to address the issue, Agarwal said in written testimony, pointing out that VHA’s Office of Productivity, Efficiency, and Staffing (OPES) has created tools to help program offices develop effective management strategies, systems, and studies to optimize clinical productivity and efficiency, and to support the establishment of staffing guidance.
Furthermore, Agarwal said that VHA now has a fully operational Primary Care Panel Size Staffing Model, which defines the number of active patients that may be assigned to each primary-care provider. Primary-care providers make up 34% of the physician workforce, the largest single component in VA’s health services.
Psychiatrists now account for 14% of VA’s physician workforce, and Agarwal said VHA will be distributing a directive, “Productivity Guidance for Mental Health Providers,” within the next few months.
She also said VHA intends to expand the use of work RVUs as “one of the measures to assess the productivity and efficiency of each specialty practice area throughout the organization.”
“Productivity standards are an essential component but require other contributing factors such as support staff, capital infrastructure and patient needs to determine staffing levels,” she noted in her testimony.
Meanwhile, Larry Conway, communications director for the National Association of Veterans Affairs Physicians and Dentists, said his organization supports the development of an “accurate and appropriately administered staffing and productivity system.”
The absence of a VA-wide productivity system and flaws in currently-used systems have led to productivity assessment models that are “inaccurate, nor balanced and in fact mislead and are useless in determining staffing needs and performance levels,” he pointed out.
“We reviewed the OIG Audit of Physician Staffing Levels for Specialty Care Services (December 27, 2012) and found that it confirmed many of the issues that had been brought to us,” Conway said. “The processes being used, where and when used are fundamentally flawed, based upon the wrong measurement units and, in some cases, they favor certain staff members while harming or diminishing others.”
He explained that such a system “can make a physician who performs procedures continually for their entire shift appear less ‘productive’ than a fellow physician who performs procedures only a few hours out the shift.”
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.