Most physicians providing care at VAMCs are employed by VHA. VHA Lacked Information on the Total Number of Mission-Critical Physicians Who Provided Care at VAMCs and Does Not Plan to Collect this Information

In our October 2017 report, we found that VHA’s data on physicians who  provided care at VAMCs were incomplete. Specifically, we found that  VHA had data on the number of mission-critical physicians it employed  (more than 11,000) and who provided services on a fee-basis (about  2,800), but lacked data on the number of contract physicians and  physician trainees. As a result, VHA did not have data on the extent to  which VAMCs used these arrangements and thus, underestimated its  physician use overall. Therefore, VHA was unable to ensure that its  workforce planning processes sufficiently addressed any gaps in staffing. VHA officials told us they were  working to include information on physician trainees in a new human  resources (HR) database—HR Smart—which at the time of our review,  was scheduled to be implemented in 2017. To address the limitations in VHA’s data, we recommended in our  October 2017 report that VHA develop and implement a process to  accurately count all physicians providing care at each of its VAMCs,  including physicians not employed by VHA. VHA did not concur with this  recommendation, stating that it uses other tools for workforce planning. However, VHA officials told us they do not plan to  enhance the capability of HR Smart to track contractors. VHA Has Begun to Develop Guidance for Determining Its Staffing Needs for All Physicians

In our October 2017 report, we found that VHA gave responsibility for  determining staffing needs to its VAMCs and provided its facilities with  guidance, through policies and directives, on how to determine the  number of physicians and support staff needed for some physician  occupations. Specifically, VHA provided this guidance for primary care,  mental health, and emergency medicine, but lacked sufficient guidance  for its medical and surgical specialties, including occupations such as  gastroenterology and orthopedic surgery. For these occupations, VHA  provided guidance on the minimum number of physicians, but did not  provide information on how to determine appropriate staffing levels for  physicians or support staff based on the need for care. To address this, we recommended that VHA develop and issue guidance  to VAMCs on determining appropriate staffing levels for all mission-critical  physician occupations. VHA concurred with our recommendation and  reported it would evaluate and develop staffing guidance for its medical  and surgical specialties. Since our report, VHA officials told us that on November 27, 2017, the  Executive-in-Charge for VHA signed the specialty care workgroup  charter. The primary goal of the workgroup is to develop a specialty care  staffing model that will include staffing information for all specialty care. VHA anticipates completing its work and issuing staffing guidance by  December 2018. VHA Used Multiple Strategies for Physician Recruitment and Retention, but Has Not Comprehensively Evaluated Them to Assess Effectiveness

In our October 2017 report, we found that VHA used various strategies to  recruit and retain its physician workforce, including providing assistance  recruiting for mission-critical physician occupations through the National  Recruitment Program; policies and guidance; financial incentives to  enhance hiring and retention offers; and a national physician training  program. As a result, VHA did not  have complete information on the underlying causes of the difficulties  VAMCs faced or whether its recruitment and retention strategies met its  objective of having a robust physician workforce to meet the health care  needs of veterans. To address these issues, we recommended that VHA (1) establish a  system-wide method to share information about physician trainees to help  fill vacancies across VAMCs, and (2) conduct a comprehensive, system- wide evaluation of its physician recruitment and retention efforts, and  establish an ongoing monitoring program. Furthermore, according to VHA  officials, beginning in October 2017, VHA’s Office of Workforce  Management and Consulting partnered with the Partnered Evidence- based Policy Resource Center—an internal VHA resource center—to  evaluate and recommend a systematic approach for allocating workforce  management resources, such as the Education Debt Reduction Program. VHA expects to complete its efforts by September 2018.
Why GAO Did This Study

As the demand for VHA's services grows—due, in part, to increasing demand from servicemembers returning from the United States' military operations in Afghanistan and Iraq and the growing needs of an aging veteran population—attracting, hiring, and retaining top talent is critical to VHA's mission to provide high quality and timely care for the nation's veterans.
Physicians—who provide and supervise a broad range of care including primary and specialty care—serve an integral role in VHA's mission. Certain physician types are consistently among the most difficult to recruit and retain, and are thus considered mission-critical by VHA.
Over the past two decades, GAO and others have expressed concern about VHA's ability to ensure that it has the appropriate clinical workforce, including physicians, to meet the current and future needs of veterans.
This statement is based on GAO's October 2017 report and examines (1) VHA information on how many mission critical physicians provided care at VAMCs, (2) VHA guidance for determining its physician staffing needs, and (3) the strategies VHA used to support the recruitment and retention of physicians at VAMCs, and the extent to which it has evaluated these strategies to determine their effectiveness.
For this statement, GAO updated the information from its October 2017 report and obtained information from VHA officials in June 2018 about steps they have taken to implement the 2017 recommendations.

What GAO Found

The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) continues to face challenges related to physician staffing, recruitment, and retention, though it has begun work to implement recommendations made in GAO's October 2017 report. Specifically, GAO's report found the following:
VHA's data on the number of physicians that provided care at VA medical centers (VAMC) were incomplete. GAO found that data were incomplete because they did not include data on the number of contract physicians and contained only limited data on the number of physician trainees—two types of physicians that augment the care provided by physicians employed by VHA. Thus, VHA data underestimated the total number of physicians providing care in its medical centers leaving it unable to ensure that its workforce planning processes sufficiently addressed gaps in staffing. GAO recommended that VHA implement a process to accurately count all its physicians. VHA did not concur with this recommendation, stating that it used other tools for workforce planning. VHA has since implemented a new human resources (HR) database—HR Smart—that has the capability to track each position at its VAMCs. However, VHA officials told us they do not plan to include information on physician contractors in this database.
VHA provided VAMCs with guidance on how to determine the number of physicians and support staff needed for some physician occupations, although it lacked sufficient guidance for its medical and surgical specialties. GAO recommended that VHA issue guidance to VAMCs on determining appropriate staffing levels for all physicians. VHA concurred and reported it would develop staffing guidance for its medical and surgical specialties. VHA officials told GAO VHA signed a specialty care workgroup charter November 27, 2017; the primary goal of the workgroup was to develop a specialty care staffing model that would include staffing information for all specialty care. VHA anticipates completing its work and issuing staffing guidance by December 2018.
VHA used various strategies to recruit and retain its physician workforce, but had not comprehensively evaluated them to assess effectiveness . Without such an evaluation, VHA did not have complete information on the underlying causes of the difficulties VAMCs face, or whether its recruitment and retention strategies were meeting physician workforce needs. GAO recommended VHA (1) establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs and (2) conduct a comprehensive, system-wide evaluation of VAMCs' physician recruitment and retention efforts and establish an ongoing monitoring program. VHA concurred and reported it has since taken steps to address the recommendations. For example, VHA's Office of Workforce Management and Consulting has partnered with its Partnered Evidence-based Policy Resource Center to evaluate and recommend a systematic approach for allocating workforce management resources. In addition, VHA has added the capability to track physician trainees to its HR Smart database. VHA expects to complete its efforts by September 2018 and September 2019, respectively.