Indian Health Service:
Agency Faces Ongoing Challenges Filling Provider Vacancies
GAO-18-580: Published: Aug 15, 2018. Publicly Released: Aug 15, 2018.
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Indian Health Service clinics don’t have enough doctors or nurses to provide quality and timely health care to American Indian and Alaska Native people. IHS data show an average vacancy rate for physicians, nurses, and other care providers of 25%.
IHS uses multiple strategies to recruit and retain providers, including offering financial incentives and housing. However, IHS has trouble matching local market salaries and does not have enough housing to meet the demand. One way the agency tries to fill vacancies is by hiring temporary providers, although officials said this is more costly and may result in less continuity of care.
Photo of the sign in front of an Indian Health Service building
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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.
Number of Provider Positions and Vacancy Rates by IHS Area, November 2017
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.
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 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.
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Recommendation for Executive Action
Comments: In February 2020, IHS reported that challenges in rolling-up contractor information on a national level stem from the fact that the agency often uses single contract vehicles, such as staffing companies, to hire multiple providers for temporary periods of time. IHS's contract databases do not centrally track the numbers of individual providers through such staffing contracts. The ability to analyze and compare detailed actual costs of federal hires vs. contract hires is currently limited to local information sources and on a narrow area of focus, such as one provider category or one facility at a time. IHS reported that the agency is implementing a monthly reporting requirement for IHS Areas and plans to use this information to inform decisions about resource allocation and provider staffing. We will review these reporting requirements when they have been fully implemented.
Recommendation: 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. (Recommendation 1)
Agency Affected: Indian Health Service