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Pay systems pose significant challenges to the Veterans Affairs Department's efforts to hire enough doctors and nurses to meet the growing health care needs of veterans, said lawmakers and witnesses at a Senate Veterans' Affairs Committee hearing on Wednesday.

"A simple truth of VA health care is that its providers are the real backbone of the system," said committee Chairman Daniel Akaka, D-Hawaii. "If the providers are not present, or are there but unhappy in their jobs, it is unlikely that veterans will receive the quality care they need and deserve."

A number of witnesses pointed to the growing vacancy rate of certified registered nurse anesthetists as an indication of the challenge's magnitude.

The Government Accountability Office reported in December 2007 that in fiscal 2005, the vacancy rate for CRNAs in VA was 13 percent, and 74 percent of chief anesthesiologists said they had trouble recruiting CRNAs in 2005 and 2006. Of those chief anesthesiologists surveyed, 79 percent said salaries for department CRNAs were lower than salaries at other hospitals.

Half of CRNAs were older than 51, and the average certified registered nurse anesthetist working at VA was seven years closer to retirement eligibility than those working outside the system, the agency found. Of the 43 medical facilities GAO examined, 15 reported CRNA vacancy rates of 40 percent or higher.

GAO found that those vacancies were affecting the department's ability to deliver health care services. Of the anesthesiologists surveyed, 54 percent said they temporarily closed operating rooms due to CRNA shortages, and 72 percent said those vacancies caused them to delay elective surgeries.

Sheila Cullen, medical director of the San Francisco VA Medical Center, said the problem wasn't simply that salaries in the VA system were lower, but that the pay system itself limited the center's ability to provide nurses with opportunities to advance up the salary ladder.

"Current law only allows the General Schedule salary chart to be extended out an additional 18 steps," Cullen said. "Since most of these employees are hired in difficult-to-recruit clinical specialties, their salary is often set at the higher end of the pay range. This limits their opportunity for future step increases."

Marjorie Kanof, GAO's managing director for health care, said VA didn't always have strong private sector salary data to use for comparison and to set pay levels. She cited one facility where planners resorted to using salary data from the Web site Hotjobs.com to make pay decisions.

Even the qualities that made VA an attractive employer, such as its mission to care for wounded veterans and the ability to do groundbreaking research in its labs, were undermined by structural limitations that undercut nurses' pay or work hours, said one witness.

"Unlike clinicians at most academic medical centers, VA clinicians may not fund a portion of their salaries through research grant support," said Jennifer Strauss, a health scientist at the Center for Health Services Research at the Durham VA Medical Center in North Carolina. "[VA clinicians] typically must donate their time, often performing research duties early in the morning or very late into the night after a long day of seeing patients."

Lawmakers said the pressures VA faced reflected larger challenges in the U.S. health care system.

Sen. Larry Craig, R-Idaho, said his experiences visiting VA health care facilities had convinced him that health care payment and service delivery systems were not effectively integrated, preventing patients from seeking care at the facilities of their choice and forcing health care systems to subcontract services from each other.

North Carolina Republican Sen. Richard Burr said focusing only on the VA system ignored the pressure that other hospitals and health care centers encountered as they competed for the same specialists. "VA has hired nearly 3,800 mental health workers since 2005, and may add an additional 500 in the near future," said Burr. "What impact does this have on the supply of mental health workers in the community both now and long-term? We need to be prepared to take a comprehensive view of addressing the problems."

Problems with VA services in rural communities reflect and amplify a larger crisis in rural healthcare. "Some of what bothers me about what's going on right now in veterans' health care is that veterans who live in rural areas don't live as long," said Sen. Jon Tester, D-Mont. "It's not a VA-exclusive problem. Every hospital in the state of Montana has a hard time recruiting and keeping people."

COMMENTS

• Ninety eight percent of my interactions with the VA Med System has been positive. However I have applied for a position on several occasions and never received a positive or negative reply. Similar to most Gov't HR Offices they have isolated themselves and you can no longer have face to face contact. In another instance a friend working at the VA told me that the management training he received was geared towards avoiding hireing VET's. Not sure what their problem is but an external IG might find and fix it. Robert McKuskie Posted April 28, 2008 11:36 AM
• The VA has the most backward recruitment process on the planet. They take 4-5 times longer than any private health care provider. They also think that advertising in newspapers is successful. The VA on the whole probably spends around 10 million a year on newspaper ads across the country. Their own internal documents show that they get less than 5% of their hires from the paper, but they just keep doing it. Why waste that money? Just broken all around! Ryan Markinson Posted April 15, 2008 11:57 AM
• I'm a federal worker and from what I hear this may not always be the case. From what I'm told, VA doctors don't have to pay liability insurance which is a huge cost to private sector doctors. Doctor's pay in some positions within certain cities is close or better than private sector. They also have good benifits and often only work 9-5, M-F. I do agree that the burn out may be caused by the type of patients. VA patients are often long term and elderly opposed to a various age group in private hospitals. On beginning my career 30 years ago I was told the reason we didn't have many young nurses apply was they didn't like working with elderly long term patients. SATOS Posted April 14, 2008 7:57 AM