Veterans Health Administration: Better Data and Evaluation Could Help Improve Physician Staffing, Recruitment, and Retention Strategies
Fast Facts
Does the Veterans Health Administration have enough doctors to keep up with veterans' growing health care needs? It can't be sure.
VHA knows the number of doctors it employs (over 11,000), but it doesn’t know how many contract physicians and physician trainees (e.g., medical residents) are used to meet its staffing needs. And although VHA uses multiple strategies to support the hiring and retention of physicians—including financial incentives and a physician training program—it hasn't evaluated their effectiveness.
We recommended that VHA develop a process to track all physicians, and evaluate its recruitment and retention strategies.
Photo of the Department of Veterans Affairs headquarters.
Highlights
What GAO Found
The Veterans Health Administration (VHA), within the U.S. Department of Veterans Affairs (VA), has opportunities to improve staffing, recruitment, and retention strategies for physicians that it identified as a priority for staffing, or mission-critical. For 2016, the top five physician mission-critical occupations were primary care, mental health, gastroenterology, orthopedic surgery, and emergency medicine. Specifically, GAO identified the following issues:
Incomplete information on number of physicians. VHA is unable to accurately count the total number of physicians who provide care in its VA medical centers (VAMC). VHA has data on the number of mission-critical physicians it employs (more than 11,000) and that provide services on a fee-basis (about 2,800). However, VHA lacks data on the number of contract physicians and physician trainees. Five of the six VAMCs in GAO's review used contract physicians or physician trainees to meet their staffing needs, but VHA has no information on the extent to which VAMCs nationwide use these arrangements.
VAMCs' Use of Contract Physicians, Fee-Basis Physicians, and Physician Trainees for Mission-Critical Physician Occupations at the Six VAMCs We Reviewed, as of March 31, 2017
Inconsistent productivity data. VHA measures productivity for some mission-critical physician occupations; however, mental health departments receive conflicting sets of productivity metrics from two VHA offices—the Office of Productivity, Efficiency, and Staffing and the Office of Mental Health Operations. VHA officials told us the two offices use differing data to serve different purposes, and acknowledged that while information on how to interpret the two sets of productivity data is available, VAMC officials may find the data confusing.
Lack of a comprehensive evaluation of its recruitment and retention strategies. VHA has not evaluated the effectiveness of its physician recruitment and retention strategies. One such strategy—hiring physician trainees—is weakened by ineffectual hiring practices, such as delaying employment offers until graduation. VHA's strategies could be strengthened by comprehensively evaluating the causes of recruitment and retention difficulties and identifying effective solutions.
Why GAO Did This Study
Physicians serve an integral role in VHA's mission of providing care to the nation's veterans. VHA hires more than 2,800 mission-critical physicians annually. Yet, physicians have consistently been identified by VHA as a critical staffing priority due to recruitment and retention concerns.
The explanatory statement accompanying the Consolidated Appropriations Act of 2016 directed GAO to review VHA's physician workforce. This report addresses: for the mission-critical physicians, (1) VHA data on how many physicians provide care, and (2) the extent VHA measures physician workload and productivity; and for all physicians, (3) what evaluations have been done on the effectiveness of its recruitment and retention strategies. GAO reviewed VHA documentation, such as policies and guidance, personnel data and workload measures. GAO interviewed officials from VHA Central Office, and six VAMCs and their corresponding regional offices. GAO selected the VAMCs for variation in location, facility complexity, and physician staffing levels.
Recommendations
GAO makes five recommendations, including that VA develop a process to count all physicians, provide guidance on productivity measurement, and evaluate its physician recruitment and retention strategies. VA concurred with four of the five recommendations, but not with the one to accurately count all physicians, stating that its workforce assessment tools are sufficient. However, GAO maintains that this is essential for effective workforce planning, as described in the report.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Veterans Health Administration |
Priority Rec.
The Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1) |
As of February 2024, VHA continued to disagree with the recommendation and have not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.
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| Veterans Health Administration | The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2) |
The Veterans Health Administration (VHA) concurred with the recommendation. To provide guidance to VAMCs on determining appropriate staffing levels, VHA's Office of Productivity, Efficiency, and Staffing (OPES) created the Specialty Provider Workforce Report (Report). The Report resides within VHA's Physician Productivity Performance Monitoring Tool. The Report allows VAMC leaders to analyze staffing and productivity data for each specialty service. Staffing data includes clinical time for physicians and advanced practice providers. It also includes data on the number of residents or trainees serving within the specialty and the number of support staff. The Report provides data that is adjusted by the number of clients served. VAMCs can also compare their staffing levels to similar facilities, both regionally and by complexity level, offering the same specialty service. The Report also allows the user to look at the specialty's productivity compared to the capacity of providers at the facility. Using the Specialty Provider Workforce Report, VAMCs should have the needed information to compare their facilities to other similarly situated facilities and determine the appropriate staffing levels for specialty services.
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| Veterans Health Administration | The Undersecretary for Health should ensure that when multiple offices issue similar productivity data on physician occupations, any methodological differences are clearly communicated and guidance is provided on how to interpret and reconcile the data. (Recommendation 3) |
In response to our finding, VHA leadership determined that although facilities could use Mental Health Onboard Clinical data for individualized productivity monitoring, the Office of Productivity, Efficiency, and Staffing (OPES) would be the official source issuing productivity data for physicians and that their data should be used for making productivity comparisons with external organizations. VHA communicated this decision to all field and program offices through an email in March 2018 and by updating their internal webpage with clarifications about their data. The FAQ on their internal website specifically clarifies methodological differences between the OPES and Mental Health data sets by explaining, for example, that the OPES measures do not include mental health imputed values, and that they are consistent with external methodologies and benchmarks. The VHA email, as well as a previously issued memorandum, guide staff to use the OPES data for external comparisons and as the official source of productivity data, and to use the Mental Health data for individualized productivity monitoring when needed.
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| Veterans Health Administration | The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4) |
VHA concurred with this recommendation. As of February 2024, VHA had developed a secure, online registration system for health professional trainees, including physician trainees. The system, the Account Provisioning/Deprovisioning System, allows VHA to track health professional trainees from training to VHA employment. A demonstration of the system to GAO showed that the system also allows for a system-wide method to share information about trainees, including program (e.g., cardiology, psychology, respiratory therapy, gastroenterology), program completion date (graduation date), and external contact information. As of January 2024, the VHA reported that over 31,000 health care professional trainees had been registered through the new system. The VA has made use of the system mandatory for all health professional trainees as of April 2024. Given that the new system provides a VHA-wide method to share information about physician trainees, we consider this recommendation closed.
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| Veterans Health Administration |
Priority Rec.
The Undersecretary for Health should conduct a comprehensive, system-wide evaluation of the physician recruitment and retention strategies used by VAMCs to determine their overall effectiveness, identify and implement improvements, ensure coordination across VHA offices, and establish an ongoing monitoring process. (Recommendation 5) |
VHA concurred with this recommendation. In May 2019, VHA submitted an evaluation of its physician recruitment and retention programs. The report covered use of the Education Debt Reduction Program, physician pay tables, and recruitment, retention, and relocation incentives. One result of the evaluation is that VHA provided Veterans Integrated Service Networks (VISN) with recommendations on how to efficiently allocate their recruitment, retention, and relocation incentives. Evaluating physician recruitment and retention programs will allow VHA to ensure that funds for these activities are effective and efficient.
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