- The Indian Health Service (IHS) is suffering from a clinician shortage, managing a 25 percent provider vacancy rate across all IHS territories, according to a recent report from the Government Accountability Office (GAO).
Clinician shortages have serious consequences for patients, limiting patient access to care and hindering care quality.
IHS is facing shortages for all clinician types, including physicians, nurses, nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, physician assistants, dentists, and pharmacists.
Vacancies vary across IHS regions. For example, in Oklahoma City IHS officials see a 13 percent provider vacancy rate, compared to a 31 percent vacancy rate in Bemidji, Minnesota.
There is also variation across provider types. For example, the department-wide vacancy rate for pharmacists is less than 25 percent, while vacancy rates remain at 25 percent for other provider types. For physicians, areas such as Oklahoma City saw 21 percent vacancy rates while Bemidji and Billings, Montana, saw vacancy rates near 46 percent.
These clinician shortages hamper patient access to care and care quality, in addition to employee morale, IHS facility staff told GAO. Most facilities have to cut some patient services because of ongoing vacancies.
IHS has acknowledged that it has considerable provider shortage issues and has identified key challenges to overcoming them.
For example, most IHS facilities are located in extremely rural regions. Specifically, 36 of the 102 and IHS facilities are deemed isolated hardship (ISOHAR) posts. ISOHAR posts are known to be exceptionally difficult to live in, and in these cases it’s mostly due to their rurality. These areas often experience hardships such as crime or violence, pollution, isolation, a harsh climate, or scarcity of goods.
Housing issues, limited educational opportunities, and scarce entertainment and lifestyle options also deter providers from living and working in these areas, IHS workers reported to GAO.
The agency has established some programs to overcome those challenges, although IHS does lack the resources to deploy these strategies at an effective scale.
For example, IHS offers some housing options where available, although those housing programs present their own subset of challenges.
“IHS facilities can experience additional challenges specific to recruiting and retaining providers for facilities on tribal lands,” GAO reported. “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.”
IHS also offers financial incentives such as increased salaries or loan forgiveness. However, the agency lacks the resources to offer financial incentives at scale and usually cannot keep pace with financial incentives offered in other employment markets.
The agency also uses contract providers both as a recruitment technique and in an effort to support patient care access. Currently, 13 percent of all IHS employees were Commissioned Corps who were fulfilling two-year terms.
Contract or temporary workers are more costly than salaried employees and can also be a detriment to care coordination and continuity of care.
IHS also utilized health IT such as telehealth tools to fill in care gaps. Alternative staffing models and hiring of non-physician clinicians also aim to support patient care access.
The agency does suffer from a lack of resources to fully deploy these programs, GAO stated. However, the agency must better manage their staffing data to allocate the resources it does have.
“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,” GAO said. “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.”
With agreement from IHS, GAO recommended that the agency must obtain information on all temporary provider contractors. This data must include costs associated with contractors and the number of full-time equivalents. IHS should use this data to make fully-informed decisions about resource allocation and provider staffing, GAO concluded.