STAFF SHORTAGES

VHA faces a unique set of recruitment and retention challenges.

By J.R. Wilson

THE VETERANS HEALTH ADMINISTRATION (VHA) is the nation’s largest health care provider, servicing millions of veterans ranging in age from late teens to late 90s – nearly 5 million of whom live in rural and highly rural areas. With a nationwide shortage of doctors and nurses, VHA also holds the numerical lead in shortages of primary care physicians, mental health professionals, registered nurses, licensed practical nurses (LPNs), etc. But raw numbers can be deceiving. “Our recruitment challenges mirror private-industry health care. There is an overall shortage in physicians and nurses, [and] our hiring needs are greater than anyone else’s. Due to our sheer size, our vacancy numbers do appear large, but there is always a shortage because everyone is competing for the same pool of people,” according to David Perry, acting chief officer for VHA Workforce Management & Consulting.

“Each year we identify the staffing shortages, both clinical and non-clinical. And every year, nurses, LPNs, pharmacists, and especially diagnostic radiology technicians are the ones we focus on as primary hiring needs. These shortages are in both full- and part-time staff. So, recruitment is our primary challenge. But our vacancy numbers are just one piece of a larger puzzle.”

For the VHA, that challenge is more complicated than just competing with all other health care groups, especially when it comes to finding enough of the right specialties to deal with their far-flung rural cohort.

“It’s hard to find [specialists] in the rural areas or to get those we recruit to work in those areas. There also are challenges in the higher urban areas as we compete against universities, large health care providers, etc., with a limited resource from a budget perspective in terms of what we can pay,” he explained.

“Our pay scales are comparable until you get into some highly specialized disciplines, such as cardiology, so we look at ways to share resources, such as interim staffing providers and shared resources. We just can’t get to what they can make in the private sector, so we have to be creative in other ways. We can use the Mission Act to leverage community care to help offset some of those gaps.”

The VA Mission Act of 2018 provides for community care for veterans otherwise entitled to VA care that cannot be scheduled in a timely manner to avoid lapses in health care services and ensure continuity of care, to provide care where traditional VA services are more than 40 miles away, or if a veteran’s referring clinician believes furnishing care or services in the community would be in the veteran’s best medical interest.

Another partial solution to the problem of serving patients in rural areas is a technology in which the VA has been a leader: telemedicine, wherein patients are introduced to easy-to-operate equipment to check blood pressure and perform other basic monitoring tasks at home, the results of which are then transmitted to a doctor who could be anywhere in the country. In some cases, doctors also can consult with patients by phone or computer video while checking those vitals in real time.

“It helps in areas where we’re having difficulty recruiting, so someone in a bigger population center can provide telehealth to a rural area,” Perry explained. “That compensates where we are not able to put people in remote physical locations.”

Another issue that may be a problem in the future is getting young people to take the difficult path of medical school – and the more difficult one of specialization. While medical school enrollments have been on the rise, funding shortages have been reducing the number of available residencies for more than 20 years.

That compounds another growing problem – nearly half of all physicians practicing today are 55 or older. Given that it takes a decade or more to complete undergraduate pre-med, then medical school, then an internship and a residency, even if only half of those doctors retire at age 65, there would not be enough new doctors in the pipeline to replace them. As a result, a study released this summer by the Association of American Medical Colleges predicts that by 2030, the United States will face a shortage of between 42,600 and 121,300 physicians.

“The Mission Act, in particular, was set out to help us come up with different ways to increase the number of people enrolled in medical school. However, from our perspective, there’s nothing I’m aware of that is helping drive medical students into specialty areas, and we’re not in a position to steer that conversation. But there does need to be some thought put into that, perhaps through our affiliate program, but that is a broader question than just the VA; it’s impacting health care nationwide,” Perry said.

“Another thing we’re leaning on is the increased utilization of our affiliates and leveraging their staff at some of our larger facilities as another stop-gap measure. We’re also looking at our J1 [non-citizen medical providers] population. There are two segments: foreign-born doctors who are citizens, and those in our J1 program, who are considered for employment after all other efforts to recruit have not been successful.”

Since 2014, the VHA’s Office of Inspector General has issued an annual report – “Determination of Veterans Health Administration’s Occupational Staffing Shortages” – in an effort to determine the status of staff shortages across the VHA’s various medical centers. While the FY 18 report followed a different set of rules than the four previous studies, the top five critical-need clinical occupations – especially the top two – have remained relatively consistent: medical officer, nurse, psychologist, physician assistant, and medical technologist.

Despite overall shortages, especially in rural areas, the VHA also has the nation’s highest growth rate for physicians and other clinical staff. Their reported vacancies in all sectors total about 10 percent, which Perry said is good compared to the private sector, where vacancy rates can run as high as 30 percent.

“For primary care, I have a 1 percent vacancy rate, which is incredible. Our specialties are the highest vacancies, but that varies by region,” he added. “Our nurse vacancy rate is about 9.4 percent out of 100,000 RNs, LPNs, CRNAs [certified registered nurse anesthetists], etc., so that’s a pretty good rate, as well.”

The VHA also is more susceptible to changing demographics in their patient population than most health care providers. The largest population in VA history – World War II veterans – is almost gone; of 16 million Americans who served in World War II, only about half a million were still alive in mid-2018. The largest group today are those who served in the post-9/11 military; the VA projects that veteran population will be just under 3.5 million by 2019 – and still growing. They have now surpassed the surviving veterans of the Vietnam War (1961-1975), estimated at more than 2 million.

“We are growing every year in terms of the number of veterans we have to care for, plus an aging population with increasing care needs. And as you age, you go to a more geriatric focus, which shifts the demographics of the workforce we need from other specialties. But we are not seeing the same growth in the resources we need,” Perry said.

“In the last 10 years, we’ve grown by 100,000 employees and average 2 to 4 percent growth every year. During that same period, the number of veterans also has increased. Our veteran enrollment projection right now is 3 percent between now and 2026, especially long-term services and support and priority 1-A enrollees. The driver there is the Vietnam veteran population as they age and what gets covered and is considered a service-connected disability.”

Despite growth and shortage rates Perry said compare favorably to the overall health care industry, the VA continues to seek ways to improve its recruitment and retention numbers.

“About 70 percent of doctors receive their residency training in a VA facility, which is our biggest pipeline. Those medical schools are our affiliates, and we work with them to maximize recruitment. We have a targeted focus on mental health and this year have had a positive gain of more than 500 mental health professionals. [From January through August 2018], we have hired 2,400 mental health professionals, including those 500 that are a positive increase. That’s new positions in a very tough recruitment market. In other areas, the number of total hires to new position growth is roughly 2- or 3-to-1.

“We try to maximize salaries, our relocation incentive, our Education Debt Reduction [EDR] program – which increased from $120,000 to up to a $200,000 loan reimbursement. The results of the EDR have been outstanding, one of our best recruitment and retention tools. In FY 18, we had a little more than 1,200 participating and our forecast for FY 19 is about 1,500. The program applies to clinical physicians, but any categories that are in the top 10 critical occupations are eligible. That includes mental health, nurses, etc., so long as they are involved in patient care. We do nationally targeted advertising campaigns, are expanding our efforts in telemedicine, and are working to transition medical professionals coming out of the military to work in the VA.”

In recent years, the VA has come under fire for long wait times for veterans to see doctors or schedule procedures, but Perry said a lot of progress has been made in the past five years, thanks to changes in how care is gauged.

“Staffing shortages are not an indicator of performance or impact on wait times,” he said. “Outcomes for access, quality, and satisfaction scores we see are the areas we focus on. For 2018, through June, our average wait time for primary care was 4.5 days, 8 days for specialty care, and just 3.7 days for mental health care. Same-day service in urgent care is not included, just normal scheduled appointments.

“The data we were looking at five years ago had lots of variations, and we were not held to consistent standards or monitoring, so the numbers varied widely by area. In 2014, there was a concerted effort to make access a key driver and priority; the results we see today are because of that.”

Perry has a very positive outlook on the VHA’s future in terms of both the speed and quality of care it will be able to provide a still-growing and diverse veteran population and the number of physicians and other clinical care professionals the organization will be able to field, although the raw numbers, taken out of context, still may cause concern and criticism. And if it does begin to see truly negative results, “we will look for ways to deal with those.

“If we continue on the trajectory we’re on now with our growth, I think the vacancy numbers will correspond to that growth. If I add another 10,000 physicians next year and have a 10 percent vacancy rate now, I can expect to see that vacancy rate grow as well. My focus is on looking at the outcomes on which we measure true success,” he concluded.

“How we focus on the care we deliver is the most important issue. We have a shift in demographics, with an aging population, and a shift in care coverage. Making sure we focus on the right measures is the best way to deliver on how we provide the care and services expected of us.”