Background Indian Health Service IHS was established within the Public Health Service in 1955 to provide  health services to members of AI/AN tribes, primarily in rural areas on or  near reservations. IHS provides these services directly through a network  of hospitals, clinics and health stations, while also providing funds to  tribally operated facilities. These federally and tribally operated facilities  are located primarily in service areas that are rural, isolated, and  underserved. In fiscal year 2017, IHS allocated about $1.9 billion for  health services provided by federally and tribally operated facilities.  Federally operated IHS facilities, which received over 5.2 million  outpatient visits and over 15,000 inpatient admissions in 2016, provide  mostly primary and emergency care, as well as some ancillary and  specialty services in 26 hospitals, 55 health centers, and 21 health  stations. According to IHS, federally operated IHS hospitals range in size  from 4 to 133 beds and generally are open 24 hours a day for emergency  care needs; health centers offer a range of care, including primary care  services and some ancillary services, such as pharmacy, laboratory, and  X-ray services, and are open for at least 40 hours a week; and health  stations offer only primary care services on a regularly scheduled basis  and are open fewer than 40 hours a week. The 12 IHS area offices are responsible for distributing funds to the  facilities in their areas, monitoring their operation, and providing guidance  and technical assistance (see fig. 1). In addition, five human resources  regional offices assist the area offices in the recruitment and hiring of  providers. IHS federally operated facilities employ both federal civil service  personnel and Commissioned Corps officers. IHS may pay higher  salaries for certain federal civil service providers through the development  and implementation of special pay tables, which specify the ranges of  salaries that these certain providers can receive. According to IHS  officials, the Commissioned Corps officers follow the same process for  applying for positions at IHS as federal civil service employees. However,  the Commissioned Corps officers are uniformed health professionals  whose pay and allowances are different. IHS also supplements its  workforce capacity with both temporary and long-term contracts with  individual physicians or a medical staffing company. IHS downloads information on all funded and active positions from the  Capital Human Resource Management System, an HHS data system  used for personnel and payment transactions that IHS began using in  2016 to track all employee vacancies. According to IHS officials, the  accuracy of the data is verified quarterly by regional human resources  officers. As the IHS health care workforce also includes Commissioned  Corps officers—who have a separate personnel system—the information  on Commissioned Corps officers assigned to IHS are entered into the  Capital Human Resource Management System manually, according to  IHS officials. Rural Health Care Delivery  Challenges According to the National Rural Health Association, the challenges of  rural health care delivery are different than those in urban areas. These  challenges include those related to more complex patient health status  and poorer socioeconomic conditions, as well as physician workforce  shortages. According to the Agency for Healthcare Research and Quality,  compared with their urban counterparts, residents of rural counties are  older, poorer, more likely to be overweight or obese, and sicker. Those  living in rural areas also have greater transportation difficulties reaching  health care providers, often traveling great distances to reach a doctor or  hospital. Exacerbating these challenges is a relative scarcity of medical  providers in rural areas compared to urban areas. For example, the  National Center for Health Statistics reported the primary care physician- to-patient ratio in rural areas in 2012 was 39.8 physicians per 100,000  people, compared to 53.3 physicians per 100,000 in urban areas. 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. (See fig. 2) However, variation in vacancy rates existed among provider types across  IHS areas. For example, while the overall percentage of vacancies for  physicians, nurses, nurse practitioners, dentists, and physician assistants  each exceeded 25 percent, the vacancy rate for pharmacists was less  than 25 percent. In addition, for certain provider types in some areas,  more than one-third of the positions were vacant. For example, although  29 percent of the total positions for physicians across these 8 areas were  vacant, the vacancy rate ranged from 21 percent in the Oklahoma City  area to 46 percent in the Bemidji and Billings areas. (See fig. 3.) As another example, although 27 percent of the total positions for nurses  across these 8 areas were vacant, the vacancy rate ranged from 10  percent in the Oklahoma City area to 36 percent in the Albuquerque and  Bemidji areas. (See fig. 4.) Similarly, across these 8 areas 32 percent of the total positions for nurse practitioners were vacant,  ranging from 12 percent in the Oklahoma City area to 47 percent in  the Albuquerque area; 27 percent of the total positions for dentists were vacant, ranging from  14 percent in the Phoenix area to 39 percent in the Bemidji area; and 30 percent of the total positions for physician assistants were vacant,  and although 4 of the areas had few such positions (the Albuquerque,  Bemidji, Oklahoma City, and Portland areas each had 7 or fewer  positions), the percentage of vacancies in the 4 areas with 15 or more  such positions ranged from 21 percent in the Phoenix area to 40  percent in the Billings area. In contrast, 13 percent of the total positions for pharmacists were vacant,  ranging from 3 percent in the Bemidji area to 17 percent in the  Albuquerque area. For more information about the vacancies for specific  clinical positions, see appendix I. While sizeable vacancies existed across provider types and areas, the  majority of positions in all eight areas were occupied by civilians, and  about 13 percent were filled by Commissioned Corps officers who are  fulfilling assignments with a minimum 2-year term. The percentages of  positions by IHS area that were vacant, filled by civilians, and filled by  Commissioned Corps officers as of November 2017 are shown in figure  5. IHS Officials Identified  Challenges to Filling  Provider Vacancies, As  Well As Negative Effects  of Vacancies on Patient  Care and Provider  Satisfaction IHS officials told us they have experienced considerable challenges in  filling vacancies for providers—as well as negative effects on patient care  and provider satisfaction when positions are vacant. According to IHS  officials, the rural locations and geographic isolation of some IHS facilities  create recruitment and retention difficulties. IHS data indicate that 36 of  the 102 IHS facilities, including four hospitals, are identified as isolated  hardship (ISOHAR) posts. Agency documentation describes ISOHAR  posts as ‘‘unusually difficult, which may present moderate to severe  physical hardships for individuals assigned to that geographic location,’’  and states that physical hardships may include crime or violence,  pollution, isolation, a harsh climate, scarcity of goods on the local market,  and other problems. In addition, IHS has reported that insufficient  housing, substandard schools, lack of entertainment opportunities, and  shopping centers located more than three hours away are all typical not  only of ISOHAR posts, but also of many other IHS facility locations.  Officials stated that, especially for job candidates and employees with  families, these can be critical factors in choosing whether or not to accept  or stay in a position. For example, officials from the Portland Area office  told us the Colville Service Unit has experienced challenges recruiting  physicians because the service unit is 110 miles away from Spokane, and  many of the smaller towns nearby have limited amenities—including  limited employment opportunities for spouses and school systems that  may not meet the expectations of some prospective employees. In addition to hardships generally associated with rural locations, IHS  facilities can experience additional challenges specific to recruiting and  retaining providers for facilities on tribal lands. For example, Navajo area  officials told us that providers who are non-native or are not married to a  tribal member generally must go off the reservation to find housing if it is  not provided by IHS. According to IHS, the Navajo Nation is one of the  largest Indian reservations in the United States, consisting of more than  25,000 contiguous square miles and three satellite communities, and  extending into portions of Arizona, New Mexico, and Utah. Living off the  reservation can result in long commutes, contributing to a difficult work- life balance. Furthermore, IHS officials noted, public transportation such  as buses or trains do not exist in proximity to most IHS facilities. 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. Officials from multiple facilities we visited told us they have had to  cut certain patient services due to ongoing provider vacancies. For  example, officials from the Phoenix Area office told us the Nevada Skies  Youth Wellness Center, an adolescent substance abuse treatment center,  decreased the number of beds available due to staffing vacancies.  Similarly, officials from the Rosebud Hospital stated the facility has  diverted obstetrics patients to other facilities since July 2016 due to a  shortage of physicians, nurses, and nurse anesthetists. During the  diversion, those patients were referred to other hospitals in Valentine,  Nebraska, and Winner, South Dakota—about 45 miles away. An official  from the Sioux San Hospital said that because of vacancies in the  diagnostic testing laboratory, the hospital stopped conducting Chlamydia  tests in-house and instead sends specimens out to another laboratory for  testing. As a result, the official stated it takes about a week longer to get  the test results, which can delay treatment. In addition facility staff we  interviewed told us the increased stress and fatigue of providers working  to make up for staffing shortages results in decreased employee morale.  These staff stated that, in some cases, this stress and fatigue has caused  providers to leave IHS. One doctor we spoke with described this dynamic  of vacancies begetting additional vacancies as a “never-ending cycle” for  the facility. 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. Specifically, IHS has provided financial incentives,  professional development opportunities, and some access to housing.  The agency has also taken steps to recruit students and connect with  potential applicants through webinars, career fairs, and conferences. 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. IHS also offers student loan repayments, in return for health  professionals’ commitment to work at IHS for a specified period of time. Special salary rates. IHS offers special higher salary rates for  physicians, dentists, nurses, CRNAs, certified nurse midwives, nurse  practitioners, optometrists, pharmacists, and physician assistants.  IHS officials stated that special salary rates are an important  recruitment and retention tool for providers, and that without them,  federally operated IHS facilities would be at a competitive  disadvantage with the private sector, VHA, and tribally operated  facilities. In 2015 IHS reported that recruiting and retaining CRNAs  was “an ongoing problem for IHS—mostly due to pay,” and the  agency rarely had “a sufficient applicant pool.” IHS reported “CRNA  services were integral to IHS operations” and without the ability to  recruit and retain these providers, IHS was “at risk of having to curtail  services to clients.” As a result, according to IHS officials, the  agency developed special salary rates for CRNAs, which became  effective on December 31, 2015. As of November 2017, IHS had no  CRNA vacancies. However, according to IHS officials, the agency has only developed  seven national special pay tables and two local special pay tables for  Alaska, as of January 2018, due to a lack of human resources personnel  trained in this process. Officials told us only one human resources staff  person at IHS is experienced with developing special pay tables, which  takes a substantial amount of work. However, they stated that this task is  only one of her job responsibilities, and she can complete about one  special pay table each year. In comparison, according to an official, VHA  has developed and regularly revises over 3,000 special salary rates  based on local market conditions. For example, IHS officials stated that  Phoenix Indian Medical Center cannot offer salaries that are competitive  with VHA because salaries for providers in the Phoenix area are relatively  high compared to national salaries, and IHS has not developed local  salary rates in the Phoenix market. For example, using pay rates effective  January 7, 2018, a nurse just starting a career in the Phoenix area could  make $63,871 at VHA (local pay table), versus $44,835 at IHS (national  pay table). Although offering increased salaries is an important strategy that IHS  uses for recruitment, IHS still experiences challenges in offering  competitive salaries. Officials from two area offices told us the maximum  amount for a physician salary or certain nursing salaries were not enough  for some potential hires, who sought employment elsewhere. While IHS  may seek approval from HHS to exceed the maximum salary of certain  pay tables, IHS officials said the approval process can be lengthy, which  has resulted in the loss of promising candidates—including emergency  medicine, general surgery, radiology, and anesthesiologist providers.  Similarly, officials from one area office stated that federally operated IHS  facilities have experienced challenges competing with other health care  systems in recruiting local health care providers, including tribally  operated facilities. For example, officials from the Oklahoma City area  office told us their area has four of the largest American Indian tribes in  the country running their own health systems. According to these officials,  in addition to IHS funds, these tribes use money from other sources to  pay health care salaries. IHS officials explained that, as a result, tribes  can pay higher salaries and may be able to offer other incentives that IHS  is unable to provide. Recruitment, relocation, and retention incentives. IHS may offer  recruitment, relocation, and retention incentives. Specifically, for  positions that are difficult to fill or for individuals who are unlikely to  accept the position without an incentive, IHS may offer potential  employees a recruitment incentive up to 25 percent of their annual  salary. IHS may also pay a relocation incentive for a current employee  who must relocate for a position that would otherwise be difficult to  fill.  In addition, IHS may pay a retention incentive of up to 25  percent of an employee’s current salary if he or she (1) has unusually  high or unique qualifications or if there is a special need of the  agency, which makes retention essential, or (2) is likely to leave IHS  without the retention incentive. Officials from the Phoenix area office  told us IHS facilities use the retention bonuses extensively for nursing  staff, in particular, to help match the market pay. IHS also analyzed  the recruitment and retention of nurses and, as a result of this  analysis, requested an exception to the 25 percent limit on  recruitment, relocation, and retention incentives, from the Office of  Personnel Management (OPM). In December, 2017, OPM approved  IHS’s request to offer incentives up to 50 percent, and IHS officials  told us that they are currently reviewing implementation options. Loan repayment. IHS’s Loan Repayment Program pays provider  education loans in exchange for an initial two-year service  commitment to practice in health facilities serving AI/AN  communities. Recipients agree to serve two years in exchange for  up to $20,000 per year in loan repayment funding and up to an  additional $5,000 per year to offset tax liability, which IHS pays  directly to the Internal Revenue Service. Loan repayment recipients  can extend their initial two-year contract on an annual basis until their  original approved educational loan debt is paid. In fiscal year 2017, a  total of 1,267 providers—about 8 percent of the federal IHS  workforce—were receiving IHS loan repayments. This included 434  new two-year contracts, 396 one-year extension contracts, and 437  providers starting the second year of their fiscal year 2016 two-year  contract. However, IHS’s Loan Repayment Program is not able to pay  for the loans of all providers who request it due to limited funding.  According to officials in one area office, this has caused providers to  either decline a job offer or leave IHS. According to IHS’s fiscal year  2019 budget justification, in fiscal year 2017, 412 providers employed  by IHS who applied for loan repayment, did not receive one. An  additional 376 applicants either declined a job offer because they did  not receive loan repayment funding or were unable to find a suitable  assignment meeting their personal or professional needs. Officials in  the Billings Area Office told us several physicians stated during exit  interviews that they were leaving because they did not receive the  loan repayment funding they hoped to receive. According to area  office officials, the Billings area lost 5 physicians in 2 weeks because  they were not awarded loan repayments. In addition to its own loan repayment program, IHS has worked with  HHS’s Health Resources and Services Administration (HRSA) to increase  opportunities for providers to apply for loan repayment through the  National Health Service Corps. Specifically, IHS worked with HRSA to  increase the number of facilities deemed medically underserved and  therefore designated Health Professional Shortage Areas. According to  IHS, this resulted in 684 health care delivery sites for placement of  National Health Service Corps providers, and the number of placements  increased to 443 providers as of August 2016. As of January 2018,  according to IHS officials, there were 499 providers serving at 797 eligible  sites. Applicants cannot receive loan repayment from more than one  program concurrently. Professional Development  Opportunities Officials from several facilities told us they provide access to professional  development opportunities for IHS employees as a retention tool. For  example, Northern Navajo Medical Facility (Shiprock) officials said they  are sending nurse managers and two to three potential future leaders to  the American Organization of Nurse Executive trainings. Officials told us  this training allows the nurses to network with private executives and look  at fellowships. In addition, Chinle Comprehensive Health Care Facility  officials told us they paid for a 2-year residency at University of Texas  Health Science Center so one of their dentists could obtain additional  training in pediatric dentistry. Officials told us that, in return, the dentist  agreed to stay at the Chinle Comprehensive Health Care Facility for 6  years. In addition, Shiprock service unit officials told us they have offered  their providers, through a partnership with the University of New Mexico,  an online Masters of Science in Public Health program in health  management. Housing When housing is limited near IHS facilities, IHS has made some housing  available to assist with recruitment and retention of providers. 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. At four of the seven  facilities we visited—the Kayenta Health Center, Chinle Comprehensive  Health Care Facility, Rosebud Hospital, and Pine Ridge Hospital—we  observed some staff housing. Kayenta Health Center. Officials from Kayenta Health Center told us  that they provide 158 housing units, from 1 bedroom to 4 bedrooms.  In addition, the facility has a 19-unit building, similar to a hotel (fully  furnished), for temporary contract providers. Officials said they are  considering opening units in this building to permanent employees. Chinle Comprehensive Health Care Facility. Officials from Chinle  Comprehensive Health Care Facility told us there are 264, 1 to 4  bedroom housing units available for providers both on its campus and  nearby. IHS officials also told us they provide access to 19 parking  spaces for camping vehicles. Rosebud Hospital. Officials from Rosebud Hospital stated they  provide 150 housing units and are also constructing a 19-unit hotel- style building. They said that most, if not all, candidates from outside  of the area ask about housing unit availability when deciding whether  to accept a position. Pine Ridge Hospital. Officials from Pine Ridge Hospital told us that  IHS also provides 105 housing units for its employees. IHS officials  explained the housing is a necessity for on-call providers because  staff without on-site housing are required to commute extreme  distances in very harsh environments to locate housing outside of  reservation boundaries. See figure 6 for examples of government-subsidized provider housing  near the Kayenta Health Center, Chinle Comprehensive Health Care  Facility, Rosebud Hospital, and Pine Ridge Hospital. See appendix II for  information about housing provided by one selected tribe. However, there is a greater demand for housing than IHS can provide.  During our site visit, Chinle Health Care Facility officials stated that  government-subsidized housing availability to meet employee demand is  severely limited at all of their three facilities, and the availability of private  housing in the community is “non-existent.” As a result, IHS officials from  Chinle told us that some providers commute 60 to 90 minutes to work  one-way each day. IHS officials told us that, after conducting a needs  assessment in 2016, they determined the unmet need for housing at IHS  facilities was 1,100 units. According to these officials, the needs  assessment also helped them identify some of the greatest needs for  housing. The President’s fiscal year 2017 budget proposal for IHS  requested $12 million to build new staff housing units “in isolated and  remote locations for healthcare professionals to enhance recruitment and  retention.”  According to agency officials, based on its needs  assessment, HHS provided $24 million to build new staff housing units at  the Rosebud and Pine Ridge hospitals in the Great Plains area, at the  Crownpoint and Chinle health care facilities in the Navajo areas, and at  the Supai clinic in the Phoenix area. Student Recruitment  Efforts IHS has also taken steps to recruit future providers by providing  scholarships, externships, internships, and residency rotations to health  professional students. Scholarships. IHS’s scholarship program provides financial support  to qualified AI/AN candidates in exchange for a minimum 2-year  service commitment within an Indian health program. Nearly 7,000  AI/AN students have received scholarship awards since the program  started in 1978. The awards include (1) scholarships for candidates  enrolled in preparatory or undergraduate prerequisite courses in  preparation for entry to a health professions school, (2) pre-graduate  scholarships for candidates enrolled in courses leading to a bachelor’s  degree, including pre-medicine, pre-dentistry, and pre-podiatry, and  (3) health professions scholarships for candidates who are enrolled in  an eligible health profession degree program. According to IHS, in  fiscal year 2017, there were 805 new scholarship applications  submitted. After evaluating the applications, 331 applications were  deemed eligible for funding, and the program was able to fund 108  new awards. The IHS Scholarship program also reviewed applications  from previously awarded scholars who were continuing their  education. In fiscal year 2017, 154 continuation awards were funded.  In addition to the scholarship program, according to IHS officials, the  agency funds two medical students enrolled at the Uniformed Service  University of the Health Sciences each year. Each graduate agrees to  a 10-year obligation to IHS after medical school graduation and  completion of training. In future years, IHS endeavors to fund two  additional medical students at the Uniformed Service University of  Health Sciences. Externships and internships. IHS provides scholarship recipients  with opportunities to receive clinical experience in IHS facilities. In  fiscal year 2017, the agency funded 94 students, who were employed  for 30 to 120 workdays per calendar year. In addition, IHS provides  externships to students temporarily called to active duty as  Commissioned Corps officers through the Commissioned Officer  Student Training and Extern Program (COSTEP). IHS officials said  that the agency funded about 60-70 students in COSTEP in 2016.  IHS also offers a Virtual Internship program through a partnership with  the Department of State. Virtual interns spend 10 hours a week from  September through May working remotely on their projects, which  have included producing bilingual Navajo and English videos for rural  health clinics, developing Navajo-specific health education materials  on palliative care, improving behavioral health data collection  methods, and creating social media strategies and campaigns for  health promotion. For the 2017-2018 academic year, about 15  students are participating in virtual internships with IHS. Residency rotations. IHS service units offer rotation opportunities for  medical, nursing, optometry, dental, and pharmacy residents as a  recruitment tool because research shows students are likely to stay  and practice medicine in the area where they studied. For example,  the Oklahoma City area has a Memorandum of Agreement with the  Oklahoma State College of Medicine, which permits area officials to  annually recruit up to two residents from the current year’s residency  class to become federal employees while completing their residency  program. For every year that IHS sponsors the residents’ position at  the university, the resident has a one-year service obligation. In  addition, IHS officials from Chinle stated that the service unit  participates in educational agreements with numerous universities  and residency programs to host medical students, nursing students,  and medical residents for rotations. According to officials, recent  graduates from residency programs applying for permanent positions  with the Chinle Comprehensive Health Care Facility often cite prior  rotations at the service unit, or word of mouth from students or  residents who have rotated through the service unit, as a reason for  applying. The IHS Pharmacy Resident Program is another recruitment  program that offers residency training to pharmacists who are willing  to serve in high-need locations. Pharmacy residents who are  Commissioned Corps officers are required to complete 2 years of  service at an IHS federal or tribal facility. Twenty-six Commissioned  Corps and civilian pharmacists participate in the Pharmacy Residency  Program. See app. II for information on residency programs at tribally  operated facilities. Connecting with Potential  Applicants IHS officials said they have conducted webinars and career fairs in an  attempt to connect with health professional students. For example, in  2016, IHS conducted two informational webinars to recruit Commissioned  Corps applicants to facilities in the Great Plains area with critical clinical  vacancies. According to IHS officials, approximately 60 applicants  attended the two webinars, resulting in 15 nurse hires. In addition,  Nashville area officials stated that the area office conducted a marketing  campaign at the National Congress of American Indians Conference. Officials explained that the area office provided information about  desirable aspects of living in the Nashville area and collected e-mail  addresses and areas of interest from potential job candidates. IHS’s  Office of Human Resources also partners with HRSA’s Bureau of Health  Workforce by participating in nationwide virtual career fairs to promote the  National Health Service Corps scholarship and loan repayment  opportunities. IHS has also worked with the Office of the Surgeon General to increase  the recruitment and retention of Commissioned Corps officers. In May  2017, the Office of the Surgeon General gave IHS priority access to new  Commissioned Corps leads—meaning IHS has at least 30 days to make  contact with potential applicants to the Commissioned Corps before other  agencies have the opportunity to contact them. According to IHS officials,  since being given priority access to Commissioned Corps leads, the  agency has made 20 direct clinical care selections, of which 15 have  entered on duty. 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. Specifically, IHS provides telehealth services;  implements alternative staffing models, including hiring nurse  practitioners and physician assistants in lieu of physicians; temporarily  assigns Commissioned Corps officers to alternate duty stations as  needed; and contracts with temporary providers. IHS’s telehealth services include two agency-wide programs that provide  teleophthalmology and telebehavioral health services. Teleophthalmology. The IHS Joslin Vision Network (IHS-JVN) Teleophthalmology Program provides annual diabetic eye exams to  AI/AN patients in almost all IHS areas with federally operated  facilities. According to IHS, patients’ retinal images are scanned  locally and sent to a reading center where doctors interpret the  images and report back. Officials told us the IHS-JVN program  examined 22,000 patients in 2016. Telebehavioral health. The Telebehavioral Health Center of  Excellence provides direct care services through video conferencing  to patients at remote facilities from providers at IHS facilities that are  able to provide the services. These services are provided in all IHS  areas with federally operated facilities, and more than 5,800 patient  visits occurred in 2016. Additionally, officials told us there are regional  telebehavioral health programs, such as in the Oklahoma City area  that, combined with the Telebehavioral Health Center of Excellence,  saw over 10,000 patients in 2016. IHS officials stated that patients  appreciate the telebehavioral services in their communities, because  they are the only behavioral health services available in many  communities. The IHS psychiatrist who provides services is located in  Oklahoma City because, according to IHS officials, it is easier to  recruit providers to a more urban location. In addition to these agency-wide telehealth programs, IHS officials  identified multiple other local telehealth arrangements that facility staff  have developed to help maintain patient access to medical services. For  example, there is a diabetes consultant for the Portland area who  conducts telenutrition services. There is also a teledermatology program  for the Phoenix Area federal facilities operated out of the Phoenix Indian  Medical Center. Additionally, several service units—including Pine Ridge  Hospital, Rosebud Hospital, and the Sioux San Medical Center—have  contracts for emergency department telehealth services. Figure 7 shows  telehealth equipment in the Rosebud Hospital emergency department. Implementing Alternative  Staffing Models Staff from multiple facilities told us they have implemented alternative  staffing models to focus on hiring for non-physician practitioner positions  because these positions are slightly easier to fill. For example, Northern  Navajo Medical Center officials told us the facility, facing an emergency  department physician shortage, hired physician assistants and nurse  practitioners instead. These officials said they converted two physician  positions into four physician assistant and nurse practitioner positions. In  addition, Chinle officials stated that they added two physician assistants  to the urgent care department due to complaints about patient wait times,  and patient wait times have decreased as a result. Officials also  mentioned dental therapists as an additional type of clinical professional  who may be added to the Chinle Health Care Facility staffing model  because the service unit has been unable to recruit and retain enough  dentists to meet patient need. Commissioned Corps  Deployments and  Temporary Duty  Assignments IHS officials stated that they have worked with the Office the Surgeon  General to deploy Commissioned Corps officers, mainly to the Great  Plains area, and have also coordinated voluntary temporary duty  assignments of Commissioned Corps officers (within IHS and from other  agencies) to temporarily fill staffing shortages or meet other mission- critical needs. IHS officials stated that Commissioned Corps officers  may also be temporarily assigned to an IHS site to provide services, such  as behavioral health support during a suicide cluster. Temporary Contract  Providers IHS officials from 9 of the 10 geographic areas with federally operated  facilities and all seven facilities in our review told us they regularly use  temporary contract providers—such as through locum tenens contracts  and contracts with university fellowship programs—to maintain patient  access to care when positions are vacant. Locum tenens. Officials from the Kayenta Health Center said they  contract with temporary providers to compensate for vacancies, and  the facility contracts with about 9 providers who rotate to fill 3 vacant  emergency department positions. Officials from the Portland area  stated that they use temporary providers when there is a staffing  shortage with providers. They explained that the Portland area has  provider vacancies that have been open for years, and temporary  providers fill these vacancies for an extended period of time, usually  with a rotating series of providers. Chinle Health Care Facility officials  said temporary providers, when of sufficiently high quality, have been  recruited to join the permanent corps of civilian service staff. However,  they told us locum tenens can cost between $50,000-$200,000 more  annually than permanent physicians’ salaries, exclusive of benefits,  depending on the specialties and hourly rates associated with the  contracts. They said they are finding that increasingly higher hourly  rates are needed to ensure a sufficient supply of high-quality  temporary providers. IHS officials at all levels of the agency told us they prefer to hire  permanent providers, rather than use locum tenens contracts. Facility  officials explained that persistent turnover in temporary staff may  jeopardize continuity of care. For example, Sioux San Medical Center  officials expressed concern about the quality of the care provided by  temporary contractors, as well as the consistency of the care provided  because the contractors rotate frequently. IHS officials told us that  many providers prefer to be on contract due to the higher  compensation rates as a contractor, even when taking federal benefits  into account. University physicians. IHS officials explained that area offices may  also contract with university fellowship programs to provide visiting  providers. For example, according to IHS, the Chinle Health Care  Facility has entered into long-term contractual agreements with two  academic fellowship programs—University of California-San  Francisco Health Program and the University of Utah Global Health  Fellowship. Officials told us these programs provide U.S. residency- trained, board certified physicians interested in global health to work  6-month assignments alternating with another fellow at an  international site. In addition, IHS officials stated that the Navajo area  office is collaborating with the University of California-San Francisco  and its global health fellowship to assign global health fellows to a  Navajo Area site for 6 months out of each year. The officials explained  that 24 fellows were placed in Navajo-area facilities in 2017 at costs  substantially lower than that of locum tenens contracts. According to  IHS, the Great Plains area office has collaborated with the University  of Washington’s global health fellowship program to assign global  health fellows in Internal Medicine to Pine Ridge Hospital for 11- month placements. Agency-wide information on the extent to which facilities use these  temporary providers, and the amount spent on them, is not readily  available to IHS leadership. While IHS has agency-wide information on  vacancies through the Capital Human Resource Management System,  IHS delegates the acquisitions process for temporary provider contracts  to the head of each area-level Contracting Office. Therefore, agency-wide  information on the number of full-time equivalent employees that are  temporary providers working at IHS facilities, as well as the cost of these  providers, is not readily available. As discussed, officials we spoke with  at IHS facilities told us that temporary providers can cost more depending  on the specialties and hourly rates. Without agency-wide information on  the extent to which such providers are used, IHS is not fully informed  about facilities’ reliance and expenditures on temporary providers or their  potential effect on patient care, which is inconsistent with federal internal  control standards regarding the availability of relevant information to  facilitate management decision making and performance monitoring.  Specifically, federal internal controls standards state that agency  management should obtain, process, and use quality information to make  informed decisions and evaluate the agency’s performance in achieving  key objectives and addressing risks. 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. However, despite efforts to recruit and retain providers, IHS  continues to face considerable challenges to overcome its long-standing  struggle to fill sizeable provider vacancies, including geographic isolation  and limited amenities. Although IHS is authorized to offer recruitment and  retention incentives, such as loan repayments and subsidized housing,  the demand for these incentives has been greater than the agency can  meet due to resource constraints. However, more complete information  on contract providers could help IHS officials make decisions on where to  better target its limited resources to address gaps in provider staffing and  ensure that health services are available and accessible to American  Indian/Alaska Native people across IHS facilities. 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.  (Recommendation 1) Agency Comments We provided a draft of this report to HHS and the Department of Veterans  Affairs (VA) for review and comment. We received written comments from  HHS that are reprinted in appendix III. HHS concurred with our  recommendation. In its comments, HHS stated that IHS plans to update its policies by  December 2018 to include a centralized reporting mechanism  requirement for all temporary contracts issued for providers. HHS also  stated that, upon finalization of the policy, IHS will broadly incorporate  and implement the reporting mechanism agency-wide and maintain it on  an annual basis. HHS also provided technical comments, which we  incorporated as appropriate. VA provided comments on a draft of this report in an email, stating that  VA officials continue to work to improve recruitment and retention of  providers at VHA to ensure that they have the correct number of  providers with the appropriate skills. We are sending copies of this report to HHS, the Department of Veterans  Affairs, and appropriate congressional committees. In addition, the report  will be available at no charge on GAO’s website at http://www.gao.gov/. If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or farbj@gao.gov. Contact points for our Office of  Congressional Relations and Office of Public Affairs can be found on the  last page of this report. Other major contributors to this report are listed in  appendix IV. Appendix I: Provider Vacancies with the  Indian Health Service (IHS) Appendix I: Provider Vacancies with the Indian  Health Service (IHS) IHS data collected in November 2017, included the number of positions  and vacancies for several types of providers, including physicians,  nurses, dentists, pharmacists, nurse practitioners, certified registered  nurse anesthetists, certified nurse midwives, and physician assistants.  Most of these positions are in the 8 of 12 IHS areas in which IHS has  substantial direct care responsibilities. Vacancies for nurse practitioners,  nurse midwives, dentists, pharmacists, and physician assistants are  provided in this appendix. Nurse practitioners. Nationwide, 97 of 303 positions were vacant in  November 2017, and vacancy rates in the 8 areas in which IHS has  substantial direct care responsibilities ranged from 12 percent in the  Oklahoma City area to 47 percent in the Albuquerque area. (See fig. 8) Certified nurse midwives. Nationwide, 8 of 55 positions were vacant in  November 2017. See table 1. Dentists. Nationwide, 81 of 306 positions were vacant in November 2017  and vacancy rates in the 8 areas in which IHS has substantial direct care  responsibilities ranged from 14 percent in the Phoenix area to 39 percent  in the Bemidji area. (See fig. 9.) Pharmacists. Nationwide, 80 of 637 positions were vacant in November  2017 and vacancy rates in the 8 areas in which IHS has substantial direct  care responsibilities ranged from 3 percent in the Bemidji area to 17  percent in the Albuquerque area. (See fig. 10.) Physician assistants. Nationwide, 37 of 125 positions were vacant in  November 2017. See table 2. Appendix II: Tribal Strategies of Housing  Units and Physician Residency Programs to  Recruit and Retain Healthcare Providers Tribal officials from the Chickasaw Nation and Choctaw Nation described  their use of strategies to address vacancies, which were very similar to  strategies used by the Indian Health Service (IHS). Like the IHS, one  tribe uses the availability of housing units near its medical facility as a  recruitment tool for health care providers. Both tribes that described their  strategies to recruit and retain providers told us they use their physician  residency program in Family Medicine as a recruitment tool. Availability of housing units near the medical facility. Tribal  officials from the Choctaw Nation told us the tribe uses housing  units—58 housing units that range from studio apartments to multi- room houses—as a recruitment strategy for providers. The provider  housing units are occupied by physicians, as well as by physician  residents who need housing during their residency or for medical  students doing clinical rotations through the facility. According to tribal  officials, a factor they considered in making housing units available for  providers was the location of its hospital in a rural area of Oklahoma,  in a town with a population of about 1,000, which lacks sufficient  housing. In September 2017, tribal officials told us all the available housing units  were occupied, and the tribe was in the process of constructing at least  two 4-bedroom houses. See fig. 11 for photos of a completed multi-room  house and one under construction. Offering the housing units to provider  staff is also part of the tribe’s overall strategy of offering quality-of-life  benefits to attract and retain providers. Implementing Accredited Physician Residency Programs. Tribal  officials we interviewed noted that they developed physician training  programs—specifically graduate medical education, commonly known  as residency training—which they use as an important recruitment  tool for physicians. One tribe has implemented its Family Medicine  residency program, while the other tribe intends for its Family  Medicine residency program to be operational in July 2018. Both  residency programs are accredited by the American Osteopathic  Association, in addition to the American College of Osteopathic  Family Practice for one tribe and the American Council for Graduate  Medical Education for the other tribe. One program is accredited for 3  resident physicians per year for a total of 9 physician residents at a  time, while the other program is accredited for 4 resident physicians  per year. We previously found that physicians may practice in geographic areas  similar to those where they complete their residency training. Tribal  officials with the implemented Family Medicine residency program told us  it is successful in that they hired 7 of the 9 residents who completed the  residency program. There is also a retention benefit—current providers  have the opportunity to stay up-to-date on the latest medical treatment  methods by serving as either mentors or as faculty for the residents. Appendix III: Comments from the  Department of Health and Human Services Appendix IV: GAO Contact and Staff  Acknowledgments GAO Contact Staff  Acknowledgments In addition to the contact named above, Kathleen M. King (Director), Ann  Tynan (Assistant Director), Kelly DeMots (Assistant Director/Analyst-in- Charge), Sam Amrhein, Kristen Anderson, Muriel Brown, Kaitlin  Farquharson, Peter Mann-King, Maria Ralenkotter, Lisa Rogers, and  Jennifer Whitworth made key contributions to this report.
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. 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.