This story was originally published June 25, 2018. As part of MedPage Today‘s year-end review of the year’s news, we are republishing it along with an update on what has happened since with VA staffing.
WASHINGTON — Imagine a job where you’re getting paid as much as your boss — and possibly more.
That’s the case for doctors at the Department of Veterans Affairs (VA), according to Max Stier, president and CEO of the Partnership for Public Service, an organization that promotes careers in the public sector. Stier spoke at a hearing last week by the House Veterans Affairs Health Subcommittee on problems in recruiting and retaining employees at VA medical centers.
“You’re paying medical center directors less than individual physicians in a marketplace where those folks can make four, five, or six times that amount” in the private sector, he said. “[If you] change that… those folks are going to figure out a lot of answers [to the VA’s problems].”
High turnover is another problem, he added. “Over the past 6 years, the VA has seen nearly one-third of its personnel leave.”
Several Hiring Challenges
Subcommittee chairman Neal Dunn, MD (R-Fla.), discussed a recently released report from the VA’s Office of Inspector General on clinical and non-clinical personnel shortages at VA facilities. “Many VA facilities struggle to hire custodians, police officers, and human resource professionals just as they struggle to hire doctors and nurses,” said Dunn. “To no one’s surprise, the report found a wide variety of staffing needs… and consistent challenges due to a lack of quality applicants, an inability to compete with the private sector, and high turnover problems… The VA can’t function without high-performing, appropriately staffed facilities.”
One of the reasons this problem hasn’t been fixed is a lack of leadership at the top levels of the VA, said Rep. Julia Brownley (D-Calif.), the subcommittee’s ranking member. “As this committee considers staffing shortages, it would be irresponsible to ignore the VA’s vacant executive suite,” she said.
“It has been nearly 5 weeks since the president announced his nominee for secretary of VA, however it took until yesterday [June 20] to formally submit [Robert Wilkie’s] nomination [for VA secretary] to the Senate,” she said.
“It’s been 16 months since the VA had a permanent undersecretary of health, and no less than nine deputy undersecretary and assistant deputy undersecretary positions are without permanent appointees. How can the VA be expected to deliver timely, quality healthcare to over 9 million veterans when this administration refuses to prioritize the need for stable, qualified, fully vetted leaders within the agency?… This administration needs to lead by example, and that means putting leadership in place who’ll get the job done.”
Physicians Are ‘Mission Critical’
The physician shortage at the VA is especially significant, said Debra Draper, director of healthcare at the Government Accountability Office, which has also issued reports on the personnel shortages. “Physicians provide and supervise a broad range of care,” she said. “Factors such as the VA’s lengthy hiring process, a limited supply of candidates, and a highly competitive recruitment environment have resulted in physicians occupying the top spot on VA’s annual list of ‘mission critical’ occupations.”
And the problem has been going on for a long time, she added. “Over the past 2 decades, we and others expressed concerns about the VA’s ability to ensure it has the appropriate clinical workforce to meet current and future needs… In 2016, physician losses were [found to] steadily increase over the previous 5 years due to voluntary resignations and retirements.”
Draper also criticized the agency for not knowing exactly how many physicians are in its employ. “In our October report, we recommended that the VA implement a systematic process to count all of its physicians; the VA didn’t concur with this recommendation,” she said. “Although [the VA] implemented a new database, it doesn’t plan to use the system to track physicians it doesn’t directly employ,” such as contract physicians. “We continue to believe it’s imperative for the VA to have an accurate count of all of its physicians.”
But Peter Shelby, assistant secretary for human resources and administration at the agency, pushed back on some of that assessment, noting that despite challenges with the VA’s multiple systems for tracking personnel, “our [human resource] capabilities continue to improve… Taken in context, the VA’s [overall] vacancy and turnover rates are very low. We fluctuate between 9% and 10%, which compares very favorably with the private sector.”
He also said he wanted to try new ways to recruit physicians, with a special focus on medical students. “Almost every doctor in America — about 80% of them — come through our system, and we haven’t been proactive enough in recruiting them,” said Shelby. “We’re exposed to them early in their career and we haven’t taken advantage of that.” For example, he said, “we want to bring in interns between their sophomore and junior years, and vet them then, and then bring them in between their junior and senior years and vet them again,” and then make tentative job offers to those who qualify.
Salary Caps at Issue
But one major problem with such recruitment efforts — whether for medical directors or young physicians — is that the VA bumps up against federal salary caps, he said. Committee member Rep. Beto O’Rourke (D-Texas) asked how high the salary cap for a medical center director — currently set at around $153,000 — would need to be in order for the VA to be more competitive with the private sector.
“$600,000,” Shelby replied. Later in the hearing, he said the VA doesn’t need to pay as much as the private sector because it offers a compelling mission and often has better benefits than private-sector employers — but we can’t pay at the 5% or 10% level” compared with some other jobs. Currently, the VA has 20 vacancies among its 170 medical director positions, as well as five impending vacancies, and it’s recruiting for 15 of those slots, he said.
Committee members generally were very supportive of the VA’s efforts, and several of them asked Shelby what legislation would need to be passed in order to help the VA with its recruiting goals. “In my opinion, all the years I’ve worked in healthcare, the personnel who work in these systems are the most important,” said Rep. Phil Roe, MD (R-Tenn.), chairman of the full House Veterans Affairs Committee. “I don’t care if you have a shiny new facility… People are the most important, more so than buildings, and anything we can do to help you do your job, we’re here to do.”
But one member sounded a note of skepticism about the idea of increasing salaries of VA personnel. “Can you imagine how a veteran, coming from a middle-class family and earning $34,000 a year, who can’t get an appointment for weeks and weeks, [would feel] knowing that the medical center director is being paid $600,000?” said Rep. Clay Higgins (R-La.). “I would hope we have the spirit of being able to do more with less and tapping into the patriotic service of Americans and medical professionals across the country that have a desire to serve.”