Indian Health Service: Efforts to Recruit Health Care Professionals (Fact
Sheet, 07/07/94, GAO/HEHS-94-180FS).

Indian Health Service (IHS) salary schedules for health care
professionals are set on a national basis. Thus, the base pay these
persons receive does not differ among IHS regions or areas. However,
bonuses and allowances may be paid to doctors who agree to work in
hard-to-fill locations, such as the Aberdeen Area. In many IHS areas,
health care delivery has been hampered by problems in recruiting and
retaining health care professionals, particularly doctors. The
recruitment and retention of physicians in the Aberdeen Area has been
affected by the relatively low pay; inadequate housing for medical
personnel on the reservations; remoteness of the reservations; cultural
differences between the doctors and their patients; and a general lack
of amenities, such as shopping and dining. IHS' Aberdeen Area has a
higher vacancy rate for physicians than all but one other IHS area. The
vacancy rate has been particularly high, more than 31 percent, at the
Pine Ridge hospital. IHS is now looking at the benefits of using a
physician pay structure similar to that used by the Department of
Veterans Affairs.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-180FS
     TITLE:  Indian Health Service: Efforts to Recruit Health Care 
             Professionals
      DATE:  07/07/94
   SUBJECT:  Native Americans
             Physicians
             Health care services
             Hospitals
             Health care planning
             Indian lands
             Human resources utilization
             Compensation
             Comparative analysis
             Personnel recruiting
IDENTIFIER:  Eagle Butte (SD)
             Pine Ridge Reservation (SD)
             Rosebud (SD)
             Pine Ridge (SD)
             Fort Yates (ND)
             Aberdeen (SD)
             IHS Indians Into Medicine Program
             Federal Employees Retirement System
             IHS Primary Care Resident Rotation Program
             
**************************************************************************
* This file contains an ASCII representation of the text of a GAO        *
* report.  Delineations within the text indicating chapter titles,       *
* headings, and bullets are preserved.  Major divisions and subdivisions *
* of the text, such as Chapters, Sections, and Appendixes, are           *
* identified by double and single lines.  The numbers on the right end   *
* of these lines indicate the position of each of the subsections in the *
* document outline.  These numbers do NOT correspond with the page       *
* numbers of the printed product.                                        *
*                                                                        *
* No attempt has been made to display graphic images, although figure    *
* captions are reproduced. Tables are included, but may not resemble     *
* those in the printed version.                                          *
*                                                                        *
* A printed copy of this report may be obtained from the GAO Document    *
* Distribution Facility by calling (202) 512-6000, by faxing your        *
* request to (301) 258-4066, or by writing to P.O. Box 6015,             *
* Gaithersburg, MD 20884-6015. We are unable to accept electronic orders *
* for printed documents at this time.                                    *
**************************************************************************


Cover
================================================================ COVER


Fact Sheet for the Honorable
Thomas A.  Daschle, U.S.  Senate

July 1994

INDIAN HEALTH SERVICE - EFFORTS TO
RECRUIT HEALTH CARE PROFESSIONALS

GAO/HEHS-94-180FS

Indian Health Service


Abbreviations
=============================================================== ABBREV

  FERS - Federal Employees Retirement System
  GS - general schedule
  HHS - Department of Health and Human Services
  IHS - Indian Health Service
  INMED - Indians Into Medicine
  OPM - Office of Personnel Management
  OTA - Office of Technology Assessment
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-256118

July 7, 1994

The Honorable Thomas A.  Daschle
United States Senate

Dear Senator Daschle: 

On October 27, 1993, you requested that we conduct a study of Indian
Health Service (IHS) employment practices.  You specifically
requested that we determine (1) if there are any differences in the
salary schedules within the various IHS service areas and (2) how
current manpower recruitment programs are working in IHS' Aberdeen
Area.  You also asked us to compare IHS' and the Department of
Veterans Affairs' (VA) hiring practices with specific emphasis on how
the pay, benefits, and bonuses for health care professionals employed
by IHS and VA are determined. 

Our review was performed at IHS hospitals in Eagle Butte, Pine Ridge,
and Rosebud, South Dakota; and Fort Yates, North Dakota.  We
interviewed IHS staff and tribal health directors at the four
locations; IHS and VA headquarters officials; and VA management
personnel at the Hot Springs, South Dakota, VA Medical Center.  We
also interviewed officials with the Office of Personnel Management
(OPM), the Aberdeen Area Tribal Chairmen's Health Board, the
University of North Dakota School of Medicine, and the University of
South Dakota School of Medicine.  (See app.  I for our scope and
methodology). 


   SUMMARY/FINDINGS
------------------------------------------------------------ Letter :1

IHS salary schedules for health care professionals are set on a
national basis.  Thus, there are no differences in the base pay these
individuals receive among IHS regions or areas.\1 However, certain
bonuses and allowances may be paid to physicians who agree to work in
hard-to-fill locations such as the Aberdeen Area.  In many IHS areas,
the provision of health care has been hampered by IHS' difficulty in
recruiting and retaining qualified health care professionals,
especially physicians.  The recruitment and retention of physicians
in the Aberdeen Area is hampered by a number of factors, including
relatively low pay; inadequate housing for medical personnel on the
reservations; remoteness of the reservations; cultural differences
between the physicians and their patients; and a general lack of
amenities, such as shopping and dining, that are found in urban
areas.  IHS' Aberdeen Area has a higher vacancy rate for physicians
than all but one other IHS area.  The vacancy rate has been
particularly high, over 31 percent, at the Pine Ridge hospital.  IHS
is currently examining the benefits of using a physician pay
structure similar to that used by VA. 


--------------------
\1 IHS health facilities are located in 12 regions or areas.  IHS'
Aberdeen Area contains facilities in Iowa, North Dakota, Nebraska,
and South Dakota. 


      IHS SALARY SCHEDULES
---------------------------------------------------------- Letter :1.1

Health care professionals in IHS are either paid under Title 5, U.S. 
Code or are paid as members of the Public Health Service Commissioned
Corps, which is authorized under Title 42.\2 Basic salaries under
both pay options are based on nationwide pay schedules and do not
vary by location.  However, physicians can receive additions to their
basic pay and these can vary substantially.  For example, physicians
can receive higher pay for being board certified, having a specific
specialty, and working in a certain location.  Generally, physicians
working in the Aberdeen Area qualify for higher allowances or special
pays.  (See section 1.)


--------------------
\2 The Commissioned Corps is a career system for health care
professionals in the U.S.  Public Health Service, of which the IHS is
a component.  The Commissioned Corps was established in 1889 and is
one of the nation's seven uniformed services (the others being the
Army, Navy, Air Force, Marine Corps, Coast Guard, and the National
Oceanic and Atmospheric Administration Corps).  As such, the
Commissioned Corps follows the military model in its rank and
benefits systems, and is subject to mobilization in case of national
emergency. 


      RECRUITMENT PROGRAMS
---------------------------------------------------------- Letter :1.2

The IHS Aberdeen Area Office established an Office of Professional
Services in 1987 to develop and implement a recruiting program to
meet the physician staffing needs of the area's medical facilities. 
The office recruits physicians who have received government
scholarships and have service obligations to IHS, physicians wishing
to have portions of their school loans repaid by IHS, and others.  In
addition, staff at IHS hospitals are actively involved in recruiting
physicians by maintaining contacts at medical schools and conducting
recruiting programs in locations that have relative surpluses of
physicians.  In spite of these efforts, there is a continual
shortfall of physicians wishing to work for IHS in the Aberdeen Area. 
In fact, as of April 1994 the four service units we visited had eight
physician vacancies out of 40 authorized positions. 

Although recruiting physicians for the Aberdeen Area is difficult, we
were told that recruiting nurses is less troublesome and that there
are often more applicants for nursing positions than there are
vacancies.  Recruiting for nurses is conducted by an area office
nurse recruiter and by staff at the individual hospitals.  Unlike
physicians, many nurses are from the vicinity of the hospitals in
which they work and are Native Americans.  Nursing schools are also
located on some reservations in the Aberdeen Area.  (See section 2.)


      IHS AND VA COMPENSATION
---------------------------------------------------------- Letter :1.3

Health care professionals in IHS are paid under different pay
structures than their counterparts in VA.  As previously stated, IHS
physicians and nurses are either paid under Title 5, U.S.  Code, or
are paid as members of the Commissioned Corps, which is authorized
under Title 42.  Conversely, VA physicians and nurses are paid under
Title 38, U.S.  Code. 

Title 5 salaries paid to IHS physicians are generally lower than
those paid to VA physicians under Title 38.  In addition, there are
distinct differences between Title 5 and Title 38.  Specifically,

  Title 38 uses local peer review boards, rather than agency
     personnel offices, to evaluate the qualifications of candidates. 
     This could result in a better match of a candidate's
     qualifications with job needs. 

  Title 38 pay rates are based on an individual's relative skills and
     knowledge.  Salaries may be increased above minimum levels,
     depending on the qualifications of a candidate.  This could
     provide VA greater opportunity to compete in shortage categories
     by allowing higher salaries to be paid than would be possible
     under Title 5. 

Physicians paid under Title 5 as well as those paid under Title 38
are eligible for a variety of bonuses.  Bonuses are paid under Title
5 according to a physician's specialty, work location, board
certification, and length of contract.  Bonuses are paid under Title
38 for similar reasons and include those for full-time employment,
work location, scarce medical specialty, and board certification. 
Benefits under the two systems differ somewhat.  IHS physicians
working under the provisions of Title 5 earn 13 days of annual leave
but are paid overtime for work above 40 hours a week.\3 VA physicians
earn 30 days of annual leave a year but are considered to be
available for work at all times and receive no overtime pay. 

Basic salaries for registered nurses are based on nationwide pay
schedules under Title 5 and in the Commissioned Corps.  Under Title
38, salaries are set locally and are based on prevailing rates.  In
addition, Commissioned Corps nurses may be eligible for housing and
subsistence allowances.  Unlike physicians, nurses receive no
additional special pays.  Benefits for Title 5 and Commissioned Corps
nurses are similar to those furnished Title 5 and Commissioned Corps
physicians.  All nurses under Title 38 earn 26 days of paid annual
leave a year, regardless of the number of years of service. 

In December 1993, OPM notified the Departments of Defense, Justice,
and Health and Human Services (HHS) that it plans to permit them to
exercise Title 38 pay authority.  Specific plans to apply Title 38
within these organizations will be discussed by an interagency
committee consisting of representatives of OPM, VA, and the agencies
that will be given the opportunity to exercise Title 38 authority.  A
working group of the interagency committee was formed in March 1994. 
However, an IHS workgroup that is reviewing recruiting and retention
problems has compared various components of Title 5 and Title 38 and
has recommended that caution be taken in applying Title 38 in IHS. 
For example, the workgroup believes that (1) Title 38's complex
special pay categories for physicians may confuse candidates and (2)
pay in rural areas may be lower for nurses under Title 38 than it
currently is under Title 5 because Title 38 nursing salaries are set
locally and are based on the prevailing wages paid in the area. 

Depending on specialty and work location, IHS' Commissioned Corps
physicians may receive lower pay than either Title 5 or Title 38
physicians.  However, they receive more lucrative benefits, such as
retirement after 20 years service and generally free medical care for
themselves and their dependents.  (Section 3 contains a detailed
discussion of the pay, benefits, and bonuses paid under Title 5,
Title 38, and to the Commissioned Corps). 


--------------------
\3 Annual leave earned is determined by the years of service. 
Employees earn 13 work days a year for the first 3 years, 20 days a
year during the 4th through 14th years, and 26 days a year afterward. 


      EFFORTS TO ENHANCE
      RECRUITING AND RETENTION
---------------------------------------------------------- Letter :1.4

Several studies have addressed IHS' recruiting and retention problems
and have proposed solutions.  For example, a 1987 study by the Office
of Technology Assessment (OTA) recommended increasing physician
salaries in hard-to-fill locations, reestablishing a scholarship
program for physicians, and transferring certain physicians from
other Public Health Service agencies to IHS.  An IHS workgroup is
currently studying recruiting and retention problems and anticipates
a final report by September 1994.  The workgroup is addressing pay
issues, the need to increase funding for recruiting incentives, and
cultural issues. 

IHS has a number of initiatives that are under way and are designed
to help recruit and retain health care professionals.  IHS supports
Indians Into Medicine (INMED), a program initiated by the University
of North Dakota, that is designed to provide academic, financial, and
personal support for Native American students who are in colleges or
professional schools preparing for health careers.  IHS also provides
scholarships to Native American students who are working toward
degrees in health areas.  Scholarship recipients agree to work for
IHS for 2 to 4 years after graduation.  In addition, IHS will pay for
school loans for health care professionals agreeing to work for IHS. 
Up to $30,000 a year can be paid towards such loans, along with an
allowance to pay the income tax on the benefit.  (See section 4.)


   AGENCY COMMENTS
------------------------------------------------------------ Letter :2

We provided a draft of this fact sheet to responsible agency
officials and have incorporated their comments where appropriate. 
These officials generally agreed with the information presented. 


---------------------------------------------------------- Letter :2.1

If you have any questions about this fact sheet please contact James
A.  Carlan, Assistant Director, at (202) 512-7120, or Joseph J. 
Buschy, Senior Evaluator, at (303) 572-7351.  Other evaluators who
made contributions to this report include Cheryl A.  Brand, Donna M. 
Bulvin, Mary Ann Curran, and Donald C.  Hahn. 

Sincerely yours,

David P.  Baine
Director, Federal Health
 Care Delivery Issues


SALARY SCHEDULES WITHIN IHS
============================================================ Chapter 1

Health care professionals in IHS are paid under the general schedule
(GS) as authorized by Title 5, U.S.  Code, or are paid as members of
the Public Health Service's Commissioned Corps.  Basic salaries as
well as bonuses and allowances differ significantly between the two
pay systems as well as among health care occupations. 


   PHYSICIAN COMPENSATION
---------------------------------------------------------- Chapter 1:1

Physicians paid under Title 5 receive a salary based on a nationwide
pay scale for physicians.\4 For example, physicians with 3 years of
residency can start at grade GS-13 while those with 4 years of
residency can start at grade GS-14.  In addition to the starting
salaries, physicians are provided additional allowances based on a
combination of their grade, specialty, duty location, duties
performed, board certification, and the length of their contract with
IHS.  Depending on their specialty and grade, starting physicians may
be entitled to higher allowances in the Aberdeen Area and in other
hard-to-fill locations. 

Members of the Commissioned Corps receive a salary based on a
nationwide pay scale for officers in the uniformed service. 
Physicians can start at the grade of Lieutenant or 0-3.\5 Numerous
allowances or special pays are also available to physician
Commissioned Corps members including

  quarters allowance with the amount depending on whether or not the
     member has dependents (this allowance is not taxable);

  subsistence allowance (not taxable);

  variable housing allowance (not taxable) depending on the member's
     grade, work location, and housing cost;

  special pay for signing a contract to remain on active duty for a
     specified term, usually 1 or more years;

  special pay for experience based on the number of years the member
     served on active duty as a medical officer in one of the
     uniformed services and the years spent in medical internship or
     residency while not a member of the uniformed services;

  board certified pay based on service entry date and board
     certification;

  multiyear retention bonus if a contract for 2 to 4 years is signed,
     the physician is board certified or fully trained in a
     recognized specialty, and is in a grade of 0-6 (Captain) or
     below; and

  incentive special pay with the amount varying according to the
     physician's specialty and duty location. 

Table 1.1 compares starting salaries, including allowances and
bonuses, paid to selected physician specialties under Title 5 and the
Commissioned Corps in Pine Ridge, South Dakota (which is classified
by IHS as a hard-to-fill location) and Phoenix, Arizona, (which is
not classified as a hard-to-fill site). 



                          Table 1.1
           
           Examples of Starting Pay for IHS Title 5
              and Commissioned Corps Physicians


                                Pine  Phoeni    Pine  Phoeni
Specialty                      Ridge       x   Ridge       x
----------------------------  ------  ------  ------  ------
Family practice               $72,69  $70,69  $75,23  $62,23
                                   6       5       9       9
Radiology                     $82,84  $82,84  $81,23  $81,23
                                   3       3       9       9
General practice              $55,04  $55,04  $68,73  $52,73
                                   2       2       9       9
Internal medicine             $72,69  $70,69  $74,23  $63,23
                                   6       5       9       9
Obstetrics/gynecology         $82,84  $82,84  $82,23  $82,23
                                   3       3       9       9
------------------------------------------------------------
Note:  Compensation figures are estimates provided by IHS and include
allowances and bonuses.  Figures are for those who sign 2-year
contracts with IHS.  Figures for general practice assume 2 years of
residency and no board certification; 3 years of residency is assumed
for the family practice and internal medicine specialties, while 4
years of residency are assumed for the others.  Specialists are
assumed to be board certified.  Physicians are assumed to have no
dependents. 

Compensation for physicians paid under Title 5, as shown in table
1.1, varies because of the grades of the physicians and the physician
comparability allowances to which they are entitled.  The lower pay
for the general practice physician with 2 years of residency is due
in part to the physician's lower grade, GS-12.  By comparison, the
family practice and internal medicine specialties are assumed to have
3 years of residency and are graded GS-13; the other specialties are
assumed to have 4 years of residency and are graded GS-14.  Physician
comparability allowances depend on a combination of factors,
including specialty and work location.  They are higher in the
Aberdeen Area and in other hard-to-fill areas for family practice and
internal medicine. 

Basic salaries for the Commissioned Corps physicians shown in Table
1.1 are the same; all physicians would qualify for grade 0-3. 
Multiyear retention bonuses vary by specialty, while incentive
special pays vary by specialty and work location.  Incentive special
pays are higher in the Aberdeen Area for many specialties than they
are in other locations such as Phoenix.  The general practice
physician would receive no board certified pay because the physician
is assumed not to be board certified.  No variable housing allowances
are included in the examples.  The physicians may be eligible for
this allowance, depending in part on the cost of their housing.  We
were told by an IHS official that Commissioned Corps members working
at Aberdeen Area IHS hospitals and living in IHS housing would not
likely receive the variable housing allowance. 


--------------------
\4 Physicians, nurses, physician assistants, and other health care
professionals are paid from special rate salary schedules that
provide higher salaries than the regular general schedule. 

\5 Public Health Service Commissioned Corps officer ranks are similar
to those in the Navy.  A Commissioned Corps or Navy Lieutenant would
be similar to a Captain in the Army, Air Force, or Marine Corps. 


   NURSE COMPENSATION
---------------------------------------------------------- Chapter 1:2

Registered nurses paid under Title 5 receive a salary based on a
nationwide pay schedule for nurses.  Unlike physicians, they receive
no allowances for duty station or specialty.  IHS nurses with an
associate's degree generally start at grade GS-4, those with a
bachelor's degree start at GS-5 or GS-7, depending on their college
grade point average (for example, a grade point average of 3.0 may
qualify an applicant for a GS-7), and those with a master's degree
usually start at GS-9. 

Registered nurses who are members of the Commissioned Corps are also
paid on the basis of a nationwide pay scale.  Nurses with a
bachelor's or master's degree start at the grade of Lieutenant Junior
Grade or 0-2.  Those with only an associate's degree do not qualify
for the Commissioned Corps.  In addition to their basic salaries,
Commissioned Corps nurses receive a nontaxable quarters allowance,
with the amount depending on whether they have dependents, and a
nontaxable subsistence allowance.  Nurses may also qualify for a
nontaxable variable housing allowance, depending on the actual cost
of their housing and their work location.  We were told by an IHS
official that those living in low-cost housing, such as IHS housing
in the Aberdeen Area, would not likely qualify for the variable
housing allowance.  Commissioned Corps nurses can receive a one-time
$5,000 bonus if they agree to work in IHS for at least 4 years. 

Table 1.2 compares the basic pay received by nurses under the Title 5
and Commissioned Corps pay schedules.  The examples shown assume that
the nurse has no dependents and include neither a variable housing
allowance nor the one-time $5,000 signing bonus. 



                          Table 1.2
           
             Examples of Starting Pay, Including
               Allowances, for IHS Title 5 and
             Commissioned Corps Registered Nurses

                                                Commissioned
Education                          Title 5 pay     Corps pay
--------------------------------  ------------  ------------
Associate's degree                      (GS-4)      Does not
                                       $23,491       qualify
Bachelor's degree                       (GS-5)       $28,314
                                  $29,949 (GS-
                                    7) $32,558
Master's degree                         (GS-9)       $28,314
                                       $37,049
------------------------------------------------------------

RECRUITING AND RETENTION OF
PHYSICIANS AND NURSES IN IHS'
ABERDEEN AREA
============================================================ Chapter 2

The problems encountered by Aberdeen Area service unit staff in
recruiting and retaining physicians are similar to those faced by
administrators in other isolated rural areas.  Poor housing; lack of
amenities such as shopping, dining, and entertainment; little or no
employment for spouses; and inadequate public education are major
obstacles to the recruitment and retention of physicians. 
Exacerbating this situation are the cultural differences between
physicians and Native Americans, tribal politics, and extremely long
work hours caused by an inadequate number of physicians to handle the
patient workload.  These factors helped contribute to the Aberdeen
Area's 25-percent vacancy rate for physicians as of April 1994--one
of the highest of any IHS area. 


   USE OF RECRUITING AND
   RELOCATION BONUSES AND
   RETENTION ALLOWANCES
---------------------------------------------------------- Chapter 2:1

Between January 1993 and June 1994, 6 of IHS' 12 area offices used
bonuses, allowances, or both to help recruit, relocate, or retain
health care workers.\6 These offices awarded 22 recruiting bonuses
(18 to physicians, 2 to nurse anesthetists, 1 to a pharmacist, and 1
to a psychologist) but no relocation bonuses.  In addition, eight
retention allowances were awarded to physicians.  We were told by an
Aberdeen Area official that the area did not award any of these
bonuses or allowances during this period because it did not have
sufficient funding in its budget to cover such an effort and because
it found the justification and approval process excessively
cumbersome. 

Health care professionals and others who are paid under Title 5 are
eligible to receive recruitment and relocation bonuses as well as
retention allowances as authorized by the Federal Employees Pay
Comparability Act.  These bonuses and allowances can be up to 25
percent of an employee's basic salary.  Recruitment and relocation
bonuses are paid in a lump sum while retention allowances are added
to employees' pay.  There are no restrictions on the number of
bonuses or allowances an employee can receive at any one time. 


--------------------
\6 The six IHS area offices that utilized recruitment and relocation
bonuses and retention allowances were Albuquerque, Bemidji, Billings,
Navajo, Oklahoma, and Tucson. 


   RECRUITING AND RETENTION OF
   PHYSICIANS
---------------------------------------------------------- Chapter 2:2

Incentives such as scholarships and loan repayment programs encourage
physicians to work with IHS, but there is little to encourage them to
remain in the system after their obligations have been satisfied.  We
were told by an IHS official in the Aberdeen Area that 2 years is the
usual time frame that physicians stay, either because they have a
mandatory obligation from a scholarship contract, have a 2-year loan
repayment obligation, or sign a 2-year contract for bonus purposes. 

Methods used to recruit physicians into the Aberdeen Area differed
among the four service units we visited. 

  Service unit staff in Eagle Butte told us that they do their own
     recruiting.  Physicians maintain contacts with the medical
     schools from which they graduated and invite medical students to
     visit Eagle Butte.  We were told that the hospital had just
     hired a physician who previously visited the hospital as a
     medical student and another physician has tentatively agreed to
     work at the hospital in the near future.  A third physician
     recently transferred to the hospital from another IHS hospital. 
     As of April 1994, the Eagle Butte Service Unit was authorized
     nine physician positions (six family practice, one general
     medical officer, and two internal medicine).  At that time one
     vacancy existed for a family practice physician. 

  The Clinical Director at Fort Yates is from Puerto Rico and
     recruited each of the physicians at the service unit from Puerto
     Rico.  As of April 1994, the service unit was authorized four
     physician positions (all family practice) and one vacancy
     existed. 

  The Pine Ridge Service Unit has had success recruiting participants
     from the Primary Care Resident Rotation Program operated by the
     University of South Dakota.  Under this program, senior
     residents from medical schools at the University of Nebraska,
     University of North Dakota, University of South Dakota, and
     Creighton University are invited to spend 1 month working at the
     service unit.  Of 12 residents who visited the service unit in
     1992, 3 accepted positions at the unit after their residency. 

Because of the success of the program in encouraging physicians to
work at Pine Ridge, in January 1994 the Clinical Director at Eagle
Butte contacted the program director at the University of South
Dakota and expressed interest in having a similar program established
at that service unit.  The program director proposed to IHS that the
program be expanded, and according to an IHS official the expansion
was approved in June 1994. 

As of April 1994, Pine Ridge was authorized 16 physician positions (1
clinical director, 2 emergency medicine, 11 family practice, 1
obstetrics/gynecology, and 1 general surgery).  Of these positions 5
were vacant (1 clinical director, 2 emergency medicine, 1
obstetrics/gynecology, and 1 general surgery). 

  The Rosebud Service Unit has obtained most of its physicians
     through the efforts of the Aberdeen Area Office physician
     recruiter.  As of April 1994, the service unit was authorized 11
     physician positions (3 family practice, 3 general medical
     officers, 2 internal medicine, 1 obstetrics/gynecology, 1
     pediatrics, and 1 general surgery).  The pediatrician position
     was vacant. 

The lack of housing for physicians was cited as a significant problem
on three of the four reservations we visited. 

  At Eagle Butte, the lack of housing was cited as the primary
     impediment to recruiting and retaining physicians.  IHS housing
     is old and limited while other housing on the reservation for
     health care professionals is virtually nonexistent.  Mobridge,
     with a population of 3,800, is 83 miles from Eagle Butte. 
     Gettysburg, with 1,500 people, is 70 miles from Eagle Butte. 
     The nearest city with a population over 10,000 is Pierre, about
     90 miles away. 

  IHS' Pine Ridge Service Unit has over 100 housing units for its
     hospital staff, including 45 recently constructed units next to
     its new hospital.  In spite of the new units, IHS service unit
     officials told us that a housing shortage still exists and that
     the service unit cannot promise housing to any of the physicians
     it is recruiting.  The town of Pine Ridge offers very few
     services or recreational activities.  Minimal services and
     housing are available 21 miles away and off the reservation in
     Rushville, Nebraska, a town with a population of about 1,100. 
     Hot Springs, South Dakota, and Chadron, Nebraska, towns of about
     4,300 and 5,600 population, respectively, are about 1 hour away
     from Pine Ridge.  Rapid City, South Dakota, with a population of
     about 54,500, is 109 miles away. 

  IHS housing in Rosebud consists of 66 new housing units near the
     hospital and 33 older units.  Homes adjacent to the hospital can
     be promised to physicians who are being recruited.  We were told
     by IHS officials at the service unit that housing was not a
     significant problem at this service unit, compared with other
     service units. 

  IHS housing is old and limited in Fort Yates, but many hospital
     staff live in and commute from Bismarck, North Dakota, a city of
     nearly 50,000 that is approximately 1 hour's drive from the
     reservation.  We were told by IHS officials at the service unit
     that its proximity to Bismarck made employment at the hospital
     relatively attractive compared with service units in more
     isolated locations.  Fort Yates is in a relatively attractive
     setting in a wooded area on a lake, offering many recreational
     activities.  Still, isolation, the lack of housing, and the
     absence of amenities in Fort Yates were cited as reasons for
     recruiting and retention difficulties. 

Officials at two of the four service units we visited specifically
told us that tribal politics were a problem in physician retention. 
Patients who have complaints about any aspect of their treatment
freely complain to tribal council members who then complain to IHS. 
Service unit directors may be faced with tribal resolutions asking
for their removal.  For example, in February 1994 the service unit
directors in Fort Yates and Eagle Butte switched jobs with one
another because of tribal resolutions. 

The most visible sign of recruitment and retention problems in the
Aberdeen Area is the 25-percent vacancy rate for physicians as of
April 1994.  As shown in table 2.1, the vacancy rate for the Aberdeen
Area is among the highest of any IHS area. 



                          Table 2.1
           
           IHS Physician Vacancy Rates, by Area, as
                        of April 1994

                                         IHS
                                      physic  Curren  Vacanc
                                         ian       t  y rate
                                      positi  vacanc  (perce
IHS area                                 ons     ies     nt)
------------------------------------  ------  ------  ------
Aberdeen                                  89      22      25
Alaska                                    77       7       9
Albuquerque                               66       1       2
Bemidji                                   24       4      17
Billings                                  56       1       2
Nashville                                 10       3      30
Navajo                                   269      45      17
Oklahoma                                 129      21      16
Phoenix                                  132       8       6
Portland                                  36       4      11
Tucson                                    11       1       9
Total                                    899     117      13
------------------------------------------------------------
Source:  IHS Physician Vacancy Report (Apr.  28, 1994). 

IHS positions and vacancies do not include tribal positions and
vacancies.  IHS had no physician positions in its California Area;
all positions were contracted to tribes. 

In addition to adversely impacting the care provided by service
units, high vacancy rates are costly.  If care cannot be provided by
IHS physicians, patients must be treated under contract in non-IHS
facilities or by contract health care providers at the service units. 
Contract care is significantly more costly than that provided by IHS
physicians. 


   RECRUITING AND RETENTION OF
   NURSES
---------------------------------------------------------- Chapter 2:3

IHS' Aberdeen Area Office has a full-time nurse recruiter who
solicits and maintains applications for those interested in working
in service units throughout the area.  The area office also checks
OPM's nationwide listing of applicants for nursing positions when
vacancies arise.  Directors of nursing at service units in the
Aberdeen Area also recruit to fill their vacancies. 

Officials in the Aberdeen Area Office and service units told us that
recruiting registered nurses generally presents few problems. 
However, some positions requiring specialized experience can be hard
to fill.  For example, the area office recruiter told us that she is
having particular difficulty filling five vacancies in the area at
the GS-11 and GS-12 levels for nurses with diabetic experience, a
nurse educator, a nurse with psychiatric experience, and a director
of nursing.  As of January 1994, the Aberdeen Area had 321 nursing
positions and 29 vacancies for a vacancy rate of 9 percent. 

Many nurses working at the service units we visited are from the
vicinity of the towns in which their service units are located and
many are Native Americans.  They find the isolation and lack of
amenities in their towns to be less troublesome than those who move
into the area to accept nursing positions.  Some have attended
nursing school on reservations.  For example, Presentation College
has a nursing school in Eagle Butte and the Oglala Lakota College in
Pine Ridge offers a nursing program. 

Although recruiting nurses is generally not a problem, service units
expressed dissatisfaction with the length of time it takes the
Aberdeen Area Office to bring a nurse on board once a vacancy
materializes.  For example, we were told by officials at two of the
service units we visited that it takes the area office up to 6 months
to fill a vacancy.  IHS has direct-hire authority for nurses and most
other health care professionals--there is no need to have selections
made through OPM.  However, service units have not been delegated the
direct-hire authority, in part, because service units are relatively
small and do not have the resources needed to perform all necessary
staffing functions. 

Because of the extreme isolation of the area in which the service
units are located, it is hard to retain nurses who move into the
areas to obtain jobs.  Amenities such as shopping, dining, and
recreation are lacking; there are no jobs for spouses; and housing on
three of the four reservations we visited may not always be available
for nurses.  We were also told by officials at one service unit that
tribal politics impacts morale and may adversely impact retention. 


   VA RECRUITING AND RETENTION
---------------------------------------------------------- Chapter 2:4

We compared IHS' recruiting and retention problems with those of VA's
medical center in Hot Springs, South Dakota, and found similarities. 
Hot Springs, a town of about 4,300, is 64 miles northwest of Pine
Ridge and 55 miles south of Rapid City.  We were informed by VA
officials at the medical center that it is considered isolated by VA
standards. 

Recruiting at the Hot Springs VA Medical Center is handled by the
facility staff through announcements in publications, attendance at
medical seminars, and visits to medical schools.  The medical center
has direct-hire authority and can hire health care professionals
without the assistance of personnel in its central office in
Washington, D.C. 

According to medical center officials, the majority of the medical
centers' recruiting and retention problems are due to its location in
a relatively isolated area.  Unlike other VA medical centers, the Hot
Springs hospital is not associated with or near a medical school. 
Therefore, there is no professional camaraderie.  Further, Hot
Springs is a small town with limited services, limited activities for
children, few jobs for spouses, and marginal housing. 

However, staff at the medical center said that their recruiting and
retention problems were minimal compared with those of IHS' Pine
Ridge service unit, primarily because Pine Ridge's isolation and lack
of services are more severe than those of Hot Springs.  Officials at
the medical center told us that as of February 1994, they had 3
physician vacancies and 3 nursing vacancies out of a total of 20.5
physician positions and 109 nursing positions, respectively. 


COMPARISON OF PAY, BONUSES, AND
BENEFITS MADE TO HEALTH CARE
PROFESSIONALS EMPLOYED BY IHS AND
VA
============================================================ Chapter 3

Health care professionals in IHS are either paid under Title 5, U.S. 
Code or as members of the Public Health Service's Commissioned Corps. 
Of the 877 physicians employed by IHS, 477 are employed under the
Title 5 structure while 400 are members of the Commissioned Corps. 
Of IHS' 2,586 nurses, 2,111 are employed under the Title 5 structure
while 475 are Commissioned Corps members.  Compensation for VA's
health care professionals is authorized by Title 38, U.S.  Code. 
Basic pay for physicians under Title 38 is generally higher than pay
authorized under Title 5 or paid to members of the Commissioned
Corps.  But physicians under all three pay systems receive special
pay or allowances that vary according to specialty, duty location,
and other factors.  Benefits are generally more liberal under Title
38 and the Commissioned Corps than they are under Title 5. 


   TITLE 5 PAY, BONUSES, AND
   BENEFITS
---------------------------------------------------------- Chapter 3:1

As discussed in section 1, salaries for health care professionals
under Title 5 are based on nationwide pay schedules with pay being
determined by education and experience.  In addition, physicians
receive a comparability allowance that is determined by specialty,
work location, board certification, and length of contract.  Nurses
receive no such allowances.  Benefits for all health care
professionals (for example, physicians and nurses) under Title 5
include 13 days of annual leave a year to start, 13 days of sick
leave, contributory health and life insurance, and retirement
benefits under the Federal Employees Retirement System (FERS).\7

Overtime pay can also be earned. 


--------------------
\7 Employees first hired after December 31, 1983, are automatically
covered under FERS.  Generally, employees hired before 1984 are
covered under the Civil Service Retirement System unless they have
elected to transfer their coverage to FERS. 


   COMMISSIONED CORPS PAY,
   BONUSES, AND BENEFITS
---------------------------------------------------------- Chapter 3:2

Salaries for members of the Commissioned Corps are based on
nationwide pay scales.  In addition, members receive nontaxable
allowances for housing and subsistence.  Physicians may also receive
additional special pay with amounts depending on their work location,
specialty, board certification, and length of contract.  Commissioned
Corps members receive 30 days of annual leave a year, sick leave as
needed, generally free medical care for themselves and dependents,
and contributory life insurance.  They also have the option of
retiring after 20 years of service.  Members have the use of
commissary and base exchange facilities and can travel on military
aircraft if space is available.  They are also subject to
reassignment from one location to another at the discretion of IHS. 
Commissioned Corps members do not earn overtime pay. 


   TITLE 38 PAY, BONUSES, AND
   BENEFITS
---------------------------------------------------------- Chapter 3:3

VA physician salaries under Title 38 are based on nationwide pay
schedules.  These physicians can also receive special pay depending
on their board certification, duty location, specialty, and work
schedule.  VA physicians do not receive overtime pay regardless of
the number of hours worked, but can earn 30 days of annual leave and
15 days of sick leave per year.  Nursing salaries under Title 38 are
set locally and are based on prevailing rates in the vicinity of the
VA facility.  Nurses earn 26 days of annual leave a year and 13 days
of sick leave.  Both physicians and nurses in VA receive contributory
health and life insurance and retirement benefits under either the
Civil Service Retirement System or FERS. 


   DELEGATION OF TITLE 38 TO
   DEPARTMENTS OTHER THAN VA
---------------------------------------------------------- Chapter 3:4

In August 1993, OPM issued the results of its study on federal
compensation paid to medical professionals.  OPM found that Title 38
offers greater flexibility in pay setting than Title 5, and Title 38
better addresses the unique needs of health care occupations than
Title 5.  The study also found that the Title 38 classification
system is designed for health care occupations, whereas Title 5 is
oriented toward program administration.  The study concluded that
Title 38 pay provisions should be applied to the major federal
employers of health care professionals. 

In December 1993, OPM notified the Departments of Defense, Justice,
and HHS of its intent to delegate those portions of Title 38 related
to pay rates and systems, premium pay, classification, and hours of
work to those agencies.  In March 1994, an interagency committee
consisting of representatives of OPM, VA, HHS, Justice, and Defense
was formed to determine how the provisions of Title 38 will be
implemented.  Delegation agreements specify that each agency will
participate and cooperate in the activities of the committee and that
consensus must be reached before implementing specific provisions of
the delegation.  We were told by an OPM official that the committee
will review the structure of Title 38 and how it is working within VA
before drafting implementation plans. 


   COMPARISON OF PROVISIONS IN
   TITLE 38 AND TITLE 5 THAT
   IMPACT RECRUITMENT AND
   RETENTION
---------------------------------------------------------- Chapter 3:5

In January 1992, IHS formed the Quality Management Recruitment and
Retention of Healthcare Professionals Workgroup to review, among
other things, IHS' recruiting and retention problems.  During this
effort the workgroup compared various components of Title 5 and Title
38 and recommended that caution be taken before implementing the
provisions of Title 38 (examples of some of the recommendations of
this workgroup are cited in Section 4, pp.  24 to 26).  According to
the workgroup, Title 38's complex special pays for physicians may
cause confusion for candidates, and pays in rural areas may be lower
for some professionals under Title 38.  Finally, the workgroup
identified five specific issues that need to be addressed before a
decision is made to implement Title 38: 

  What are the costs of implementing Title 38.  For example, if Title
     38 results in higher salaries, will budgetary restrictions occur
     that, in turn, will result in staffing cuts? 

  Can IHS use both Title 5 and Title 38?  For example, can IHS health
     care professionals be paid under Title 5 at some locations and
     Title 38 at others? 

  Will members of the Commissioned Corps be allowed to switch to
     Title 38? 

  How will local pay rates be set?  For example, nursing pay under
     Title 38 is set locally after market surveys are conducted.  Who
     will conduct the surveys and how will they be conducted? 

  How will Indian Preference fit under Title 38?  Currently, IHS must
     give preference to Native Americans in the hiring process. 
     Would this still be a requirement, or even allowed, under Title
     38? 

In comparing the two pay systems, the workgroup noted that Title 38
uses local peer review boards, rather than agency personnel offices,
to evaluate the qualifications of candidates; Title 38 pays
individuals on their relative skills and knowledge, thus allowing VA
greater opportunity to compete in shortage categories by paying a
higher salary than would otherwise be possible; and Title 38 allows
local managers greater control over personnel decisions.  These
differences could provide managers with better matches of candidates
to job requirements and could allow them to better compete with other
employers for candidates.  The workgroup also noted that Title 38
increases the amount of annual leave and eliminates overtime pay for
physicians.  This difference may have a detrimental impact on
physicians who work considerable overtime. 

Concerns about Title 38 were expressed by IHS headquarters and
service unit staff.  For example, IHS' starting salaries for some
nurses are higher than those of the VA in Hot Springs.  Concern was
expressed that IHS may be required to lower its pay for nurses in
certain locations under the provisions of Title 38.  Also, some IHS
physicians paid under Title 5 who work considerable overtime may
receive more pay than those working for VA because VA physicians paid
under Title 38 are not compensated for overtime. 


   COMPARISON OF IHS AND VA
   COMPENSATION WITH HEALTH CARE
   PROFESSIONALS IN THE ABERDEEN
   AREA
---------------------------------------------------------- Chapter 3:6

Basic pay is only one part of the compensation packages offered
physicians in the IHS and VA.  Bonuses and allowances can be paid for
board certification, type of specialty, and work location.  These
bonuses depend on a variety of factors, such as the scarcity of the
physician's specialty and the difficulty of recruiting physicians in
specific locations. 

Table 3.1 shows examples of starting annual pay, including allowances
and bonuses, for various physician specialties under VA's Title 38
and IHS' Title 5 and for IHS' Commissioned Corps members who work in
the Aberdeen Area. 



                          Table 3.1
           
           Examples of Starting Pay for Physicians
                in the Aberdeen Area Under the
            Provisions of Title 38 and Title 5 and
                    the Commissioned Corps


Specialty       Title 38     Title 5      Commissioned Corps
------------  ----------  ----------  ----------------------
Family           $99,589     $72,696                 $75,239
 practice
Radiology       $122,589     $82,843                 $81,239
General          $72,293     $55,042                 $68,739
 practice
Internal         $89,589     $72,696                 $74,239
 medicine
------------------------------------------------------------
Note:  Compensation figures are estimates provided by VA and IHS and
include allowances and bonuses.  Figures are for full-time physicians
who sign 2-year contracts.  Figures for general practice assume 2
years of residency and no board certification; 3 years of residency
is assumed for the family practice and internal medicine specialties,
while 4 years of residency is assumed for the radiologist. 
Specialists are assumed to be board certified.  Physicians are
assumed to have no dependents. 

Starting salaries for physician assistants are also generally higher
in IHS than in VA.  In fact, we were informed by VA officials in Hot
Springs that its starting salaries for physician assistants are not
competitive with those in the private sector.  As a result, VA has
difficulty hiring individuals in this medical specialty at the entry
level.  IHS has difficulty filling its physician assistant vacancies
for the same reason.  Starting salaries shown in table 3.2 are in
ranges and depend on qualifications of the applicant. 



                          Table 3.2
           
              Starting Pay Ranges for Physician
                   Assistants in IHS and VA

Education                      Pay range
-----------------------------  -----------------------------
Bachelor's degree

IHS (GS-7)                     $28,016 to $34,829

VA                             $24,653 to $32,048

Master's degree

IHS (GS-9)                     $33,345 to $41,679

VA                             $28,648 to $37,239
------------------------------------------------------------
An official of a university in the Aberdeen Area told us that
graduates from the physician assistant program at that university
were obtaining average starting salaries of $45,000 a year.  The
1-year program requires students to have at least a 2-year nursing
degree and 2 years of nursing experience.  The official told us that
graduates have little difficulty finding jobs. 

IHS officials that we visited in the Aberdeen Area said that nursing
salaries under Title 5 are competitive with those paid in the private
sector.  Conversely, VA officials in Hot Springs told us that they
have difficulty at times competing with IHS for nursing staff because
VA's salaries for nurses are lower than those in IHS.  As shown in
table 3.3, starting salaries in IHS for nurses with bachelor's and
master's degrees are higher than those offered by VA's Hot Springs
facility. 



                          Table 3.3
           
           Starting Salaries for Registered Nurses
              With No Experience, by Educational
               Background, for IHS and VA's Hot
               Springs, South Dakota, Hospital

Education                        IHS     VA, Hot Springs
----------------------  ------------  ----------------------
Associate's degree            (GS-4)         $25,648
                             $23,491
Bachelor's degree             (GS-5)
                             $29,949         $27,186
                              (GS-7)
                             $32,558
Master's degree               (GS-9)         $31,031
                             $37,049
------------------------------------------------------------

EFFORTS TO ENHANCE RECRUITING AND
RETENTION OF HEALTH CARE
PROFESSIONALS AT IHS FACILITIES
============================================================ Chapter 4

Several studies and proposals have been made to address IHS'
difficulty in recruiting and retaining health care professionals.  In
February 1987, OTA issued its report, Clinical Staffing in the Indian
Health Service.\8 OTA's study was conducted in response to the
virtual elimination of physicians available to IHS from the National
Health Service Corps' scholarship program (see pp.  26 and 27 for
further details).  OTA listed several options for congressional
consideration, including increasing physician salaries in
hard-to-fill locations; reestablishing the National Health Service
Corps scholarship program as a source of physicians for IHS; and
authorizing the reassignment of Commissioned Corps officers from
other Public Health Service agencies to IHS.  IHS officials told us
that some of the options in the report had been addressed.  For
example, physicians now receive larger allowances in hard-to-fill
locations, and the National Health Service Corps scholarship program
was reestablished in 1990.  However, the recommendation to reassign
officers from other Public Health Service agencies to IHS has not
been acted on because no other Public Health Service agency has any
medical staff to spare. 

In 1990, the Aberdeen Area Tribal Chairmen's Health Board formulated
a proposal designed to help overcome physicians' concerns about the
extreme isolation and lack of services in the areas in which IHS
facilities are located.  The proposal called for the creation of pods
of four to eight physicians, living in major urban areas such as
Bismarck and Grand Forks, North Dakota, and Rapid City and Sioux
Falls, South Dakota, who would visit the reservations under an
established rotating schedule.  The physicians would work at their
assigned hospitals or clinics for up to 14 days and then spend up to
10 days at their home.  According to the Aberdeen Area Tribal
Chairmen's Health Board, the proposal was discussed in 1992 with
Aberdeen Area Office staff and in 1993 at a recruitment and retention
workgroup meeting.  However, area office and workgroup officials that
we contacted did not specifically recall seeing the proposal, nor
were they aware of any evaluation of the proposal by IHS or action
taken by IHS as a result of the proposal.  Similarly, officials in
IHS' headquarters were unaware of the proposal. 

IHS' Quality Management Recruitment and Retention of Healthcare
Professionals Workgroup was established in January 1992 to

     "develop and act on both short and long range strategies for
     meeting the agency needs for recruitment and retention of health
     professions."

The workgroup's final report is anticipated by September 1994, but an
interim report was issued in March 1993.  That report addressed the
need to pay competitive salaries to health care professionals;
recognized the need to increase funding for IHS' loan repayment
program; recommended a thorough study of Title 38 implementation
options; and suggested the production of community awareness,
cultural sensitivity, and federal employment videos.  In April 1994,
we were informed by an official associated with the workgroup that it
was still evaluating its interim findings and recommendations. 

IHS has a number of initiatives underway that are designed to help
recruit and retain health care professionals: 

  INMED was established in 1973 at the University of North Dakota,
     which is within IHS' Aberdeen Area.  Its objectives are to
     provide academic, financial, and personal support for Native
     American college and professional students preparing for health
     careers.  Among INMED's goals are increasing the number of
     Native American health care professionals and increasing the
     number of health care professionals serving Native American
     communities.  Since its inception, INMED has assisted 148 Native
     American health care professionals, including 86 physicians and
     62 nurses and other health care professionals.  Of the 86
     physicians, 65 have completed residency and 34 of the 65 have
     worked with Native Americans.  Of the 62 INMED participants in
     other fields, 56 have worked with Native Americans and 54 are
     still doing so. 

In 1992, after receiving proposals from the Universities of
Washington, Arizona, and Minnesota-Duluth, IHS selected
Minnesota-Duluth as a second INMED site.  The University of South
Dakota has a cooperative agreement with the University of North
Dakota's INMED program wherein students receive a part of their
education at each school. 

  The Indian Health Professions Scholarship Grant Program awards
     scholarships to Native American students who are working toward
     degrees in health areas.  The program was funded at about $7.8
     million for fiscal year 1994.  Scholarship priority is given to
     students who are attending medical schools.  In fact, we were
     informed by an IHS official that virtually all eligible Native
     American medical school students who apply for these
     scholarships are funded. 

Students who receive Indian Health Professions Scholarships agree to
work for IHS for 2 to 4 years after they graduate, depending on the
duration of their scholarships.  About 150 scholarship recipients, of
which about 8 percent are physicians, graduate from colleges and
universities annually.  In 1993, 13 physicians who were scholarship
recipients joined IHS.  We were informed by an IHS official
associated with the scholarship program that data are not readily
available showing the locations to which scholarship recipients are
assigned. 

  IHS supports medical students at the Uniformed Services University
     of the Health Sciences.  The university was established in 1972
     by the Department of Defense to train students for careers as
     medical officers in the Army, Navy, Air Force, and the
     Commissioned Corps of the Public Health Service.  Medical
     students incur obligations of 7 to 10 years active duty after
     graduation.  Nearly 2,000 medical students have graduated from
     the university since its first graduating class in 1980. 
     Historically, IHS has supported about three students per class. 
     In 1992 IHS increased the number to four per class.  The three
     students per class group has a 7-year service obligation; those
     in the 4 per class group have a 10-year obligation.  In June
     1994, three physicians with service obligations from the
     university were working for IHS in the Aberdeen Area. 

  Depending on the availability of funds, IHS will pay for school
     loans for health care professionals agreeing to work for IHS. 
     Up to $30,000 a year can be paid towards such loans, along with
     an allowance to pay the income tax on the benefit.  By law, at
     least 25 percent of funding must be provided to nurses and at
     least 10 percent to mental health care professionals.  In fiscal
     year 1993, about $10.7 million was provided to 234 physicians,
     nurses, and other health care professionals, while another 311
     persons applied but did not receive funds.  Of this amount,
     about $4.7 million was provided to 74 physicians; another 81
     applied for but did not receive funding.  About $2.5 million was
     provided to 88 nurses; another 72 applied for but did not
     receive funding. 

From fiscal years 1988 through 1993, 840 loan repayment awards were
made.  As shown in table 4.1, 11 percent of these awards were to
health care professionals working in the IHS Aberdeen Area. 



                          Table 4.1
           
            IHS Loan Program Awards, Fiscal Years
                           1988-93

                                                      Percen
                                               Total    t of
                                              awards  awards
                                                 for     for
                                              Aberde  Aberde
                                       Total      en      en
Type of profession                    awards    Area    Area
----------------------------------  --------  ------  ------
Physician                                314      15       5
Nurse                                    318      32      10
Dentist                                   76      15      20
Other professionals                      132      31      23
Total                                    840      93      11
------------------------------------------------------------
Other programs have been available in the past to assist IHS in
recruiting health care professionals: 

  IHS operated a physician assistant school in Phoenix, Arizona, from
     1971 to 1977 and a school in Gallup, New Mexico, from 1971 to
     1983.  The training schools for Native Americans were operated
     in order to encourage Native Americans to enter the health care
     area and work for IHS.  In exchange for their training,
     graduates of the schools agreed to work for IHS.  An IHS
     official who had been program director at the Gallup school told
     us that the school trained about 100 physician assistants during
     its 12 years of operation.  The schools were closed because of
     budget cuts. 

Physician assistants can provide limited medical care and supplement
physician care in areas that are unable to recruit or retain adequate
numbers of physicians. 

  The National Health Service Corps scholarship program, operated by
     HHS, has provided tuition assistance to medical students and
     others studying in the health care professions.  Recipients are
     legally obligated to work in an underserved area for 1 year for
     each year of tuition support, with a minimum 2-year obligation. 
     Scholarship recipients have been placed in IHS, community and
     migrant health centers, the Bureau of Prisons, and elsewhere. 
     Program funding declined from its peak in 1980 to virtually
     nothing in 1989.  Accordingly, obligated physicians available to
     work in IHS have decreased since 1987, as shown in figure 4.1. 
     It typically takes a physician about 7 years to complete medical
     school and residency, so there is about a 7-year lag between
     initial scholarship funding and availability for work.  Funding
     was reestablished in 1990 but students entering medical school
     in 1990 may not be available for work for about 7 years.  A
     National Health Service Corps official told us that the number
     of physicians who will eventually be assigned to IHS is unknown. 
     Unlike the Indian Health Professions Scholarship Grant Program,
     the National Health Service Corps scholarship program was not
     limited to Native Americans. 

   Figure 4.1:  Physician
   Recipients of National Health
   Service Corps Scholarships
   Assigned to IHS Facilities,
   Fiscal Years 1980-93

   (See figure in printed
   edition.)

During our review, we also solicited the opinions of tribal directors
at three of the four service units we visited.  Their suggestions for
easing the recruiting and retention problems in the Aberdeen Area
included

  increasing salaries for physicians;

  establishing a large IHS hospital in a major metropolitan area to
     serve Native Americans who must now be treated under contract
     with non-IHS providers;

  increasing loan repayment and scholarship programs;

  giving physicians more time off to be with their families rather
     than expecting them to work over 60 hours a week;

  involving health care professionals in cultural activities;

  providing better housing; and

  providing land to those wishing to build homes. 


--------------------
\8 Although the OTA report was 7 years old at the time of our review,
many of its findings and recommendations were still relevant. 


SCOPE AND METHODOLOGY
=========================================================== Appendix I

Information on IHS salaries and compensation was obtained from IHS'
headquarters and its Aberdeen Area Office.  IHS physician staffing
and vacancy statistics, both nationwide and for Aberdeen Area
hospitals, were obtained from the IHS Physician Vacancy Report as of
April 28, 1994.  We obtained VA salary and compensation information
from VA's headquarters and from its Medical Center in Hot Springs,
South Dakota.  We also obtained information from OPM on plans to
delegate VA's pay-setting authorities to other agencies. 

We discussed recruiting and retention problems with

  IHS' headquarters and Aberdeen Area Office staff;

  service unit directors, clinic directors, and directors of nursing
     at the Cheyenne River Service Unit in Eagle Butte, South Dakota;
     the Pine Ridge Service Unit in Pine Ridge, South Dakota; the
     Rosebud Service Unit in Rosebud, South Dakota; and the Standing
     Rock Service Unit in Fort Yates, North Dakota; and

  the Aberdeen Area Tribal Chairmen's Health Board. 

We compared IHS' recruiting and retention problems with those of VA's
Medical Center in Hot Springs; this center is relatively close to
Pine Ridge and is considered remote by VA standards. 

We obtained information on recruiting and retention initiatives from
IHS' headquarters, area office, and service unit staff.  We also met
with a representative of the University of South Dakota's School of
Medicine in Rapid City.  We contacted officials at the University of
North Dakota in Grand Forks to obtain information about the INMED
program and starting salaries for physician assistants.  We discussed
possible solutions to recruiting and retention problems with tribal
health directors at three of the four service units we visited. 

We performed our work between January and May 1994 in accordance with
generally accepted government auditing standards. 

