1). IHS Data Show Sizeable Provider Vacancies and Officials Identified Various Challenges to Filling Them IHS Data Demonstrate Sizeable Provider Vacancies

IHS data demonstrate large percentages of vacancies for providers in the  8 areas in which IHS has substantial direct care responsibilities. As of  November 2017, the overall percentage of vacancies for physicians,  nurses, nurse practitioners, CRNAs, certified nurse midwives, physician  assistants, dentists, and pharmacists in these areas was 25 percent,  ranging from 13 to 31 percent across the areas. 2)
However, variation in vacancy rates existed among provider types across  IHS areas. 3.) According to IHS  officials, the rural locations and geographic isolation of some IHS facilities  create recruitment and retention difficulties. IHS facility staff told us long-standing vacancies have a direct negative  effect on patient access to quality health care, as well as employee  morale. IHS Uses Multiple Strategies to Recruit and Retain Providers

In an effort to recruit and retain permanent employees, IHS has used  strategies that are similar to strategies used by VHA and tribal facilities in  our review. Salaries and Other Financial Incentives

IHS offers increased special salary rates for certain health care positions,  as well as other financial incentives, such as recruitment and retention  bonuses. Special salary rates. Area  officials told us federally operated IHS facilities in the Albuquerque, Great  Plains, Phoenix, Billings, and Navajo areas provide some government- subsidized housing for providers and their families. IHS Uses Strategies to Maintain Patient Access to Services and Reduce Provider Burnout When Positions Are Vacant, But Lacks Agency- wide Data on Use of Temporary Providers Providing Telehealth Services

In addition to its recruitment and retention strategies, IHS uses strategies  to mitigate the negative effects of vacancies by helping to maintain patient  access to services, and helping to reduce provider burnout when  positions are vacant. Officials from the Portland area  stated that they use temporary providers when there is a staffing  shortage with providers. IHS officials explained that area offices may  also contract with university fellowship programs to provide visiting  providers. IHS’s lack of agency-wide  information on the costs and number of temporary providers used at its  facilities impedes its ability to make decisions about how best to target its  resources to address gaps in provider staffing and ensure that health  services are available and accessible across IHS facilities. Conclusions

Maintaining a stable clinical workforce capable of providing quality and  timely care is critical for IHS to ensure that comprehensive health  services are available and accessible to American Indian/Alaska Native  people. Recommendation for Executive Action

We are making the following recommendation to IHS:  The Director of IHS should obtain, on an agency-wide basis, information  on temporary provider contractors, including their associated cost and  number of full-time equivalents, and use this information to inform  decisions about resource allocation and provider staffing. HHS concurred with our  recommendation.
Why GAO Did This Study

IHS is charged with providing health care to AI/AN people who are members or descendants of 573 tribes. According to IHS, AI/AN people born today have a life expectancy that is 5.5 years less than all races in the United States, and they die at higher rates than other Americans from preventable causes. The ability to recruit and retain a stable clinical workforce capable of providing quality and timely care is critical for IHS. GAO was asked to review provider vacancies at IHS.
This report examines (1) IHS provider vacancies and challenges filling them; (2) strategies IHS has used to recruit and retain providers; and (3) strategies IHS has used to mitigate the negative effects of provider vacancies. GAO reviewed IHS human resources data for the provider positions that the agency tracks. GAO also reviewed policies, federal internal control standards, and legal authorities related to providers in federally operated IHS facilities. GAO interviewed IHS officials at the headquarters and area level and at selected facilities. GAO selected facilities based on variation in their number of direct care outpatient visits and inpatient hospital beds in 2014.

What GAO Found

Indian Health Service (IHS) data show sizeable vacancy rates for clinical care providers in the eight IHS geographic areas where the agency provides substantial direct care to American Indian/Alaska Native (AI/AN) people. The overall vacancy rate for providers—physicians, nurses, nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, physician assistants, dentists, and pharmacists—was 25 percent, ranging from 13 to 31 percent across the areas.
IHS officials told GAO that challenges to filling these vacancies include the rural location of many IHS facilities and insufficient housing for providers. Officials said long-standing vacancies have a negative effect on patient access, quality of care, and employee morale.
IHS uses multiple strategies to recruit and retain providers, including offering increased salaries for certain positions, but it still faces challenges matching local market salaries. IHS also offers other financial incentives, and has made some housing available when possible. In addition, IHS uses strategies, such as contracting with temporary providers, to maintain patient access to services and reduce provider burnout. Officials said these temporary providers are more costly than salaried employees and can interrupt patients' continuity of care. However, IHS lacks agency-wide information on the costs and number of temporary providers used at its facilities, which impedes IHS officials' ability to target its resources to address gaps in provider staffing and ensure access to health services across IHS facilities.

What GAO Recommends

GAO recommends that IHS obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing.
IHS concurred with GAO's recommendation.