The attrition among VHA physicians has been of particular concern given that the Health Resources and Services Administration (HRSA) anticipates that by 2025 the national demand for physician services will exceed supply. HRSA’s Office of Rural Health Policy reported, in 2017, that physician shortages were exacerbated in rural areas, where communities struggle to attract and keep well-trained providers. This difficulty has posed a particular challenge for VHA, as approximately one in four VAMCs is located in a rural area. Most physicians providing care at VAMCs are employed by VHA. VHA also supplements the capacity of its employed physician staff by acquiring additional physician services through fee-basis arrangements or contracts. Under fee-basis arrangements, providers are paid a pre- agreed-upon amount for each service provided. Under contracts, physician services may be obtained on a short-term basis; for example, through sole-source contracts with academic affiliates. VAMCs may also use physicians who volunteer their time, who are referred to as work- without-compensation providers. In addition to VHA-employed, contract, and fee-basis physicians, VAMCs often supplement their capacity by using physician trainees, who include medical residents and advanced fellows. In 2016, 135 of the 170 VAMCs had active physician training programs. According to VHA officials, there were 43,768 medical residents who trained at a VAMC in 2016. VHA has been expanding its physician training program, as directed by the Veterans Access, Choice, and Accountability Act of 2014, as amended. In 2017, VHA added 175 physician trainee positions across VAMCs nationwide, including 3 VAMCs that did not have physician trainees prior to this expansion. VHA’s objective is to add 953 additional physician trainee positions to its VAMCs by 2025 in order to improve access and hire additional physicians. Further, VHA officials told us they want to continue to add new positions that would eventually allow all VAMCs access to physician trainees. 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. All six VAMCs included in our review used at least one type of arrangement other than employment for physicians, and five of the six used contract physicians or physician trainees. (See fig. 1.) On average, contract and fee-basis physicians made up 5 to 40 percent of the physicians in a given mission-critical physician occupation at each VAMC in our review. For example, officials from a large, highly complex VAMC told us that, in March 2017, they augmented the 86 employed primary care physicians with eight contract and three fee-basis physicians, which represented about 16 percent of their primary care physician workforce. Further, this VAMC also had about 64 primary care physician trainees providing certain medical services under the supervision of a senior physician. During the course of our work for the October 2017 report, VHA officials told us that its personnel databases were designed to manage VHA’s payroll systems, but that these databases did not contain information on contract physicians or physician trainees. 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. However, these officials were not aware of plans to add information to the database on contract physicians. Instead, VAMC leaders used locally devised methods to identify and track contract physicians, fee-basis physicians, and physician trainees. For example, one VAMC in our October 2017 review used a locally maintained spreadsheet to track its physicians under arrangements other than employment, while another VAMC asked department leaders to identify how many of these provided care within their respective departments. At each of the six VAMCs in our review, we found that department leaders were generally knowledgeable about the total number of physicians that provided care within the departments they managed. However, this locally maintained information was not readily accessible by VHA officials. 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, a VHA official acknowledged that data sources used for workforce planning may not include all types of contract physicians or work-without-compensation physicians. As we discussed in our prior report, implementing such a systematic process would eliminate the need for individual VAMCs to use their own mechanisms, such as a locally developed and maintained spreadsheet to track its physician workforce, as was done by one VAMC in our prior review. Further, local mechanisms may not be readily accessible to VHA officials engaged in workforce planning, resulting in incomplete information for decision-making purposes. Since our report, VHA officials told us that they have completed implementation of HR Smart, which provides the capability to track every position with a unique position number, and each employee’s full employment history. However, VHA officials told us they do not plan to enhance the capability of HR Smart to track contractors. We continue to believe that having a systematic and consistent process to account for all physicians who provide care across VAMCs, including physicians not employed by VHA, would help address concerns that VHA is unable to identify all physicians providing care at its VAMCs. 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. Specifically, the VHA guidance available at the time set a minimum requirement that VAMCs of a certain complexity level have at least one gastroenterologist and one orthopedic surgeon that is available within 15 minutes by phone or 60 minutes in person 24 hours a day, 7 days a week. VHA guidance did not include information on how to use data, such as workload data, to manage the demand for care or help inform staffing levels for these physician occupations beyond this minimum requirement. Officials from four of the six VAMCs we reviewed for our October 2017 report told us that because they lacked (1) guidance on how to determine the number of physicians and support staff needed, and (2) data on how their staffing levels compared with those of similar VAMCs, they were sometimes unsure whether their staffing levels were adequate. In our October 2017 report, we discussed that VHA had previously established, in 2016, a specialty physician staffing workgroup that examined the relationships between staffing levels, provider workload and productivity, veterans’ access, and cost across VAMCs for its medical and surgical specialties, including gastroenterology and orthopedic surgery. This group’s work culminated in a January 2017 report that found VHA was unable to assess and report on the staffing at each VAMC, as required by the Veterans Access, Choice, and Accountability Act of 2014, because a staffing model for specialty care had not been established and applied across VAMCs. This report made a number of recommendations, including that VHA provide guidance to its VAMCs on what level of staffing is appropriate for its mission-critical physician occupations. However, as we noted in our October 2017 report, VHA leadership had not yet taken steps to develop such staffing guidance. We reported that, according to a VHA official, other priorities were taking precedence and continued work in this area had not yet been approved by VHA leadership. Although VHA officials agreed that further steps should be taken, they did not indicate when these would occur. In our report, we concluded that until VHA issues guidance on staffing levels for certain physician occupations that provide specialty care to veterans, there would continue to be ambiguity for VAMCs on how to determine appropriate staffing levels. 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. 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. (See table 1.) In our October 2017 report, we found that VHA faced challenges using its strategies for recruiting and retaining physicians. For example, according to VHA officials, budget shortfalls in the Education Debt Reduction Program—which reimburses qualifying education loan debt for employees, including physicians, in hard-to-recruit positions—reduced VAMCs’ ability to offer this recruitment incentive to physician candidates. In addition, the relatively small number of physician recruiters in VHA’s National Recruitment Program—19 recruiters for the 170 VAMCs at the time of our report—limited their ability to understand the particular nuances of some markets, particularly in rural areas. Further, despite VHA’s large and expanding graduate medical training program, VAMCs experienced difficulties hiring physicians who received training through its residency and fellowship programs. VHA did not track the number of physician trainees who were hired following graduation, but officials told us that the number was small in comparison to the almost 44,000 physician trainees educated at VAMCs each year. We found that VAMCs faced challenges hiring physician trainees, in part, because VHA did not share information on graduating physician trainees for recruitment purposes with VAMCs across the system. VHA officials told us that recruitment efforts could be improved by developing and maintaining a database of physician trainees, but said that VHA had no such database. According to VHA officials, information sharing could help both VAMCs in geographically remote locations that do not have a residency program and help identify trainees who want to work at VHA after graduating, but who received no offers from the VAMC they trained at due to the lack of vacancies in their specialty. We also reported in October 2017 that VHA did not have complete information on whether its recruitment and retention strategies were meeting its needs. VHA had gathered feedback on barriers VAMCs face when offering financial incentives to physician candidates through its Education Debt Reduction Program and created a workgroup to look at its overall use of physician retention strategies, although it had not completed a comprehensive review of its recruitment and retention strategies to identify any areas for improvement. 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. VHA concurred with our recommendations, and reported it planned to enhance its personnel database, HR Smart, to include physician trainees. Additionally, VHA said it planned to complete a comprehensive, system-wide evaluation of the physician recruitment and retention strategies. Since our report, VHA reported taking some steps to address these recommendations. Specifically, officials told us they are working to include information in the newly implemented HR Smart database on work-without-compensation employees, such as physician trainees, and anticipate conducting pilot projects at various sites before fully implementing this capability by September 30, 2019. Additionally, officials said that they are in the process of completing a review of physician recruitment and retention incentives. 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. Chairman Dunn, Ranking Member Brownley, and Members of the Subcommittee, this concludes my statement. I would be pleased to respond to any questions you may have. For further information about this statement, please contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony. Key contributors to this statement were Janina Austin (Assistant Director), Sarah Harvey (Analyst-in-Charge), Jennie Apter, Frederick Caison, Alexander Cattran, and Krister Friday. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: 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. 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.