GAO Finds Physician Productivity, Staffing Issues at VA Centers

October 23, 2017 - Incomplete and inconsistent data on physician productivity and staffing challenges the Veteran’s Health Administration’s (VHA) ability to determine if the federal department has enough providers to address the growing health needs of veterans, a recent Government Accountability Office (GAO) report stated.

The VHA manages the largest healthcare system, with 1,252 facilities including 170 VA medical centers (VAMC).

Through the healthcare system, providers are delivering a range of care, including primary care, specialty care, mental health, surgery, and emergency medicine. Veteran health needs are rising across these areas as the population ages and the number of members who served in Afghanistan and Iraq increases.

While the VHA recruits and employs over 2,800 physicians each year to meet veteran health demands, a 2016 GAO report found that the number of physicians who quit has risen over the past five years.

If the VHA fails to boost the total number of clinical staff, as well as physician productivity, the federal department is unlikely to meet the estimated demand for healthcare services, a separate report contended.

READ MORE: How Value-Based Reimbursement Affects Physician Productivity

However, improving physician productivity and staffing may be a challenge for the VHA. The recent GAO investigation uncovered that the VHA lacks complete data on mission-critical providers, including primary care, mental health, and emergency medicine. Information was lacking on physicians employed under a fee-basis arrangement.

VAMCs maintained fee-basis arrangements with about 2,842 mission-critical physicians and an average of 1,316 of these physicians delivered care in any given pay period.

Contracted and fee-basis providers accounted for 5 to 40 percent of each mission-critical provider workforce at each of the six VAMCs analyzed by GAO.

Despite a substantial workforce, the VHA did not include data on fee-basis providers in its physician employment assessments or reports. The federal department excluded the physicians because officials could not determine the full-time equivalent contribution of the employees.

Neither the VHA’s personnel database nor VAMC-specific databases included data on contract physicians.

READ MORE: VA, HHS Healthcare Staffing Agreement to Up Vet Care Access

Instead, VAMC leaders used “locally devised methods” to find and track contract and fee-basis physicians as well as physician trainees. While VAMC leaders demonstrated extensive knowledge of these providers, VHA officials could not readily access locally maintained data sources.

The VHA also did not include contract and fee-basis provider data in workforce planning processes. VAMCSs report annually to a web-based planning system that gathers data on the national level for system-wide workforce succession planning.

The tool helps medical centers to predict the number of providers needed to meet veteran health needs. But the lack of contract and fee-basis provider data may skew the projections.

“The lack of ready access to complete information on all types of physicians, including physicians who provide care under arrangements other than employment, means VHA is not fully informed of its total physician workforce, including the extent to which its VAMCs are relying on physicians under these other arrangements,” GAO wrote.

“As such, VHA cannot ensure that its workforce planning process sufficiently addresses gaps in physician staffing, including whether staffing is appropriately allocated across VAMCs and departments, which may affect veterans’ access to care, among other issues,” the organization added.

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The GAO investigation also found that inconsistent and problematic provider data prevented the VHA from accurately measuring physician productivity for most mission-critical healthcare positions.

The VHA tracks physician productivity using the number of patients and encounters. Medical centers use the information to manage care demands and determine staffing levels.

But the information was limited to just 32 provider types and did not contain all types of services provided. For example, the data lacked work done by physicians who were not directly employed by the VHA and work done by physicians who provided evaluating and managing services for hospitalized patients.

Furthermore, the data used to calculate physician productivity may be inaccurate because of inconsistent clinical coding and time reporting by physicians. Accurate coding and time reporting is key to tracking work relative value units.

VAMC officials in mental health, gastroenterology, and orthopedic surgery departments told the GAO that data integrity issues caused them to “spend a significant amount of time trying to understand physician productivity assessments and providing interpretations to help inform management decisions.”

Mental health departments were particularly affected by data integrity problems because two separate systems calculated physician productivity for mental health providers.

Each system uses different data sets to track productivity, resulting in conflicting interpretations. For instance, one system’s estimates of psychiatrist productivity were between 10 and 35 percent more than the other system’s results.

“These problems with productivity data are inconsistent with federal internal control standards, which state that management should use and communicate quality information—that is information that is appropriate, current, complete, accurate, accessible, and provided on a timely basis— to make informed decisions and evaluate an agency’s performance in achieving key objectives and addressing risks,” the federal watchdog stated.

Additionally, GAO reported that the VHA experienced physician recruitment and retention challenges.

To recruit and keep physicians, the VHA used four key strategies: dedicated physician recruiters, policies and guidance to support healthcare employment, financial incentives (i.e. bonuses and debt reduction), and physician training programs.

However, the federal watchdog found that recruiting and retaining “hard-to-recruit” physicians at VAMCs was still challenging even with support from the National Recruitment Program. Medical center and VHA officials stated that physician recruitment and retention was difficult because of the national physician shortage, highly competitive markets, physician reluctance to work in a rural or geographically remote region, and high physician turnover.

Physician recruiters also did not always refer high-quality candidates, medical center staff stated. The recruiters also did not understand rural healthcare markets.

Physician recruiter issues may stem from an understaffed program, the VHA stated. The federal department employs 19 national recruiters for 170 VAMCs, whereas a private health system of three hospitals uses 7 recruiters.

VAMC officials also expressed concerns with interpreting VHA policies on physician recruitment and retention, which contributed to long recruitment and hiring processes.

For example, some VAMCs stated that VHA policy mandates that they post physician job announcements online for the position to qualify for financial recruitment incentives. But other medical center staff pointed out that directors possess the authority to waive the external job posting requirement, which is the correct VHA policy.

Misinterpretations resulted in some physician vacancies taking up to a year to fill. Hard-to-recruit physician positions took even longer at some VAMCs.

Financial incentives also presented a problem for VAMCs. Officials stated that the “financial incentives for recruitment and retention do not always result in competitive salary packages, and funding for incentives was often inadequate at the VAMC level.”

While the VHA boosted physician pay ranges in 2016 in response to non-competitive incentives, not all medical centers could leverage the higher ay ranges because the increase would either create a pay gap between existing and new staff and/or the centers did not have the budget.

To alleviate physician productivity and staffing issues, the GAO recommended the following to the VHA:

• Establish a process to accurately count all providers furnishing care to each medical center, including those not directly employed by the VHA

•  Publish guidance on determining physician staffing levels for all mission-critical provider positions

• Ensure that when several offices issue similar physician productivity information, any methodological differences are clearly communicated and officials have access to guidance on how to interpret and reconcile data

• Develop and implement a system-wide process for sharing information on physician trainees to help place providers in open VAMC positions

• Perform a wide-system evaluation of physician recruitment and retention strategies used by medical centers to find their effectiveness, pinpoint improvements, ensure coordination across offices, and establish a monitoring process

The VHA concurred with four of the five recommendations. The federal department did not agree that a process to count all physicians providing care at VAMCs was necessary because it already has “highly reliable systems to identify its physicians.”